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|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 3 | Page : 698-700
Reruptured Previously Coiled Aneurysm - Is it the Ideal Time to Perform Check Angiography at Six Months after Endovascular Coiling?
Anshu Mahajan, Gaurav Goel, Biplab Das, Vinit Banga
Department of Neurosciences, Medanta, The Medicity, Gurugram, Haryana, India
|Date of Web Publication||6-Jul-2020|
Dr. Gaurav Goel
Department of Neurosciences, Medanta, The Medicity, Gurugram, Haryana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mahajan A, Goel G, Das B, Banga V. Reruptured Previously Coiled Aneurysm - Is it the Ideal Time to Perform Check Angiography at Six Months after Endovascular Coiling?. Neurol India 2020;68:698-700
|How to cite this URL:|
Mahajan A, Goel G, Das B, Banga V. Reruptured Previously Coiled Aneurysm - Is it the Ideal Time to Perform Check Angiography at Six Months after Endovascular Coiling?. Neurol India [serial online] 2020 [cited 2020 Aug 10];68:698-700. Available from: http://www.neurologyindia.com/text.asp?2020/68/3/698/289007
A 61-year-old male follow-up case of balloon assisted coiling of ruptured left anterior choroidal artery aneurysm (12.1 × 9 mm) [Figure 1]a-d] presented with sudden loss of consciousness due to acute subarachnoid hemorrhage and intraventricular bleed (WFNS grade 4, SAH grade 4) [Figure 1]e and [Figure 1]f. Our institutional protocol is to performed check angiography after 6 months of endovascular coiling. His check angiography was planned 1 month later. Left parietal ventriculo-peritoneal shunt was done on his previous admission [Figure 1]f. Urgent external ventricular drain (EVD) placement was done on right side in view of his neurological status and massive intraventricular hemorrhage. His neurological status (Glasgow coma scale) improved on next day. Digital subtraction angiography (DSA) was performed which revealed significant recanalization of previously coiled aneurysm with coil compaction [Figure 1]g. Repeat endovascular coiling was planned. Stent assisted coiling and flow diverter (FD) placement options were also discussed as treatment options; however, in view of acute hemorrhage and EVD placement, balloon assisted coiling was performed [Figure 1]h. Patient was discharged after one month with modified rankin score (mRS) of 3 and was planned for early check angiography after three months. Three months after the retreatment, DSA revealed again recanalization of neck of aneurysm [Figure 2]a. Clinically, the patient had mRS of 2. This time, the patient was planned for FD placement. After loading with dual antiplatelet therapy (aspirin and prasugrel), FD placement without coiling was successfully done [Figure 2]b and [Figure 2]c. Three months follow-up check angiography was done which revealed complete occlusion of aneurysm [Figure 2]d. There is an increased rate of aneurysm occlusion and lower rates of recurrence, retreatment, and rerupture in patients treated with microsurgical clipping reported by International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial (BRAT).,, The 6-year results from the BRAT reported complete aneurysm obliteration rates of 95.7% in patients treated with microsurgical clipping and 47.9% in patients treated with endovascular coiling. However, endovascular treatment for both ruptured and unruptured aneurysm has become the treatment of choice because of lower morbidity and mortality. Neck remnants after endovascular coiling are reported in 20% to 60% of cases and presence of neck remnants after the coiling and clipping is associated with increased risk of rupture.,, Recurrences after the coiling are mainly due to coil compaction or regrowth of residual neck. There are many risk factors contributing to the recurrence of previously coiled aneurysm including large aneurysm size, broad neck, rupture status, low coil packing density, initial presence of an intraluminal thrombus, and residual neck at time of initial treatment., Most of the recurrences after endovascular coiling appears after 6-12 months posttreatment. Cerebral Aneurysm Rerupture After Treatment study investigators reported 1.1% risk of rupture for completely occluded aneurysms and a 5.9% risk of rupture for aneurysms with small residual neck. In this series rebleeding after treatment occurs mainly during the first 6-12 months. Thus, follow-up imaging is recommended to evaluate for the recanalization of aneurysm sac which may require further treatment if needed., DSA is considered to be gold standard for imaging follow-up of treated aneurysms. In our case, first treatment with endovascular coiling, small residual neck was deliberately left to save the anterior choroidal artery origin [Figure 1]d. Thus, factors in our case including large size, the small residual neck, ruptured status, and probably presence of intraluminal thrombus were responsible for the early significant recanalization and rerupture before the planned date of check angiography. In patients with above-mentioned risk factors for early recanalization, check angiography should be early planned at three months.
|Figure 1: Noncontrast computed tomography head showed acute SAH and IVH. EVD tube in right lateral ventricle (a and b). Left internal carotid artery (ICA) injection showed ICA aneurysm with anterior choroidal artery (arrow) arising from the neck of the aneurysm (c). Successful endovascular coiling was done with normal opacification of anterior choroidal artery (d). Coil mass artifacts and IVH (e and f). Significant recanalization of aneurysm noted with coil compaction (g). Recoiling of aneurysm was successfully done (h)|
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|Figure 2: Check angiogram after 3 months reveals significant recanalization of aneurysm (a). Surpass flow diverter was placed from MCA to supraclinoid ICA across the neck of aneurysm (b and c). Completely occluded previously coiled ICA aneurysm on follow up 3 months angiography (d)|
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Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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[Figure 1], [Figure 2]