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NEUROIMAGE
Year : 2014  |  Volume : 62  |  Issue : 6  |  Page : 714-715

Vanishing aneurysm during cerebral angiography complicating endovascular coiling: An unusual manifestation of intraoperative vasospasm


Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA

Date of Web Publication16-Jan-2015

Correspondence Address:
Manish K Kasliwal
Department of Neurosurgery, Suite 855, Rush University Medical Center, Chicago-60612, Illinois
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.149465

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How to cite this article:
Tan LA, Kasliwal MK, Chen M. Vanishing aneurysm during cerebral angiography complicating endovascular coiling: An unusual manifestation of intraoperative vasospasm. Neurol India 2014;62:714-5

How to cite this URL:
Tan LA, Kasliwal MK, Chen M. Vanishing aneurysm during cerebral angiography complicating endovascular coiling: An unusual manifestation of intraoperative vasospasm. Neurol India [serial online] 2014 [cited 2019 Aug 23];62:714-5. Available from: http://www.neurologyindia.com/text.asp?2014/62/6/714/149465


A 78-year-old woman presented with Hunt-Hess Grade IV and modified Fisher Grade IV subarachnoid hemorrhage [Figure 1]a and a negative computed tomography (CT) angiogram. Catheter cerebral angiography performed on post-bleed day 2 revealed a 3 mm Χ 1.2 mm inferiorly directed oblong aneurysm at the P2/P3 junction arising from a dysplastic right posterior cerebral artery [Figure 1]b. The aneurysm had a favorable dome-to-neck ratio and endovascular coiling was attempted. During injection of the parent vessel with a 1.5 F distal outer diameter Marathon microcatheter placed at the aneurysmal neck, roadmap images no longer opacified the aneurysm. After withdrawing the microcatheter, digital subtraction angiography confirmed the absence of any aneurysm opacification. This was thought to be due to microcatheter-induced vasospasm or spontaneous thrombosis of the aneurysm at the time [Figure 1]c. Attempt to relieve the suspected vasospasm with use of local nimodipine was unsuccessful when spontaneous thrombosis of the aneurysm neck/aneurysm was suspected. The next day, surveillance catheter cerebral angiography demonstrated aneurysm re-opacification [Figure 1]d. Upon repeated injection for coiling, the aneurysm again no longer opacified. The endovascular procedure was aborted and the aneurysm was successfully clipped.
Figure 1: (a) CT scan of the head showing diffuse thick SAH in the basilar cisterns eccentric to the right. (b) Cerebral angiogram demonstrating a 3 × 1.2 mm right P2/P3 junction aneurysm with the aneurysm no longer visible on cerebral angiogram as the micro-catheter was advance into the parent vessel due to intraoperative vasospasm (c). The aneurysm was again demonstrated on cerebral angiogram done on the following day (d)

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Radiographic cerebral vasospasm can occur in up to 60-70% of patients with aneurysmal SAH. [1] However, cerebral vasospasm during cerebral angiography leading to the disappearance of a ruptured aneurysm has not been described previously in the literature. The contributing factors for intraprocedural vasospasm in this case may include presence of thick subarachnoid blood, a relatively small parent vessel caliber given its location at P2/P3 junction, as well as vessel irritation from repeated attempts at micro-catheter placement. The possibility of vasospasm leading to disappearance of cerebral aneurysms such as in our case may also explain the fact that about 10-16% of patients with SAH and initial negative cerebral angiogram have aneurysms detected on subsequent diagnostic cerebral angiography. [2],[3] Non-visualization of an aneurysm during angiography is not always attributed to aneurysm thrombosis and early repeat angiography should be considered to uncover an aneurysm obscured by intraprocedural vasospasm.

 
  References Top

1.
Bakker NA, Groen RJ, Foumani M, Uyttenboogaart M, Eshghi OS, Metzemaekers JD, et al. Repeat digital subtraction angiography after a negative baseline assessment in nonperimesencephalic subarachnoid hemorrhage: A pooled data meta-analysis. J Neurosurg 2014;120:99-103.  Back to cited text no. 1
    
2.
Klimo P Jr, Schmidt RH. Computed tomography grading schemes used to predict cerebral vasospasm after aneurysmal subarachnoid hemorrhage: A historical review. Neurosurg Focus 2006;21:E5.  Back to cited text no. 2
    
3.
Chen M. Detection of angiographically occult, ruptured cerebral aneurysms: Case series and literature review. J Neurointerv Surg 2014;6:744-7.  Back to cited text no. 3
    


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