Evaluate for aneurysm and potential coilings. LICA and RICA aneurysms. This patient is an 87 years old woman with acute diffuse subarachnoid hemorrhage. She has multiple aneurysms based on CTA. It is not clear based on the CTA which aneurysm ruptured. Angiography would help further assess this and decision to coil should be made following angiography.OPERATORS: Greg ChristoforidisFLUOROSCOPY TIME: 102.8 minutesFrontal: 2611.72 mGyLateral: 2996.65 mGyPROCEDURES: 1) cerebral angiogram 2) Intracranial right PCOMA cerebral aneurysm coil embolization with balloon assistance. 3) Intracranial left PCOMA cerebral aneurysm coil embolization with balloon assistance. 4) 3-D reconstructions of intracranial right internal carotid artery 5) 3-D reconstructions of intracranial left internal carotid artery AORTA with iliac runoffs: No contraindication to closure device deployment.Right common carotid artery: No stenosis at the carotid bifurcation on the basis of NASCET criteria. There is no evidence for carotid dissection.Right internal carotid artery: There is opacification of the right anterior, middle and posterior cerebral arteries. Venous and parenchymal phases were within normal limits. The right A1 segment is small. There is a 50% irregular stenosis at the posterior bend of the cavernous RICA. There is a 4mm wide neck right PCOMA aneurysm with a pointed tip on it which is directed posteriorly. The right PCOMA originates at the base of the aneurysm. There is a 2mm right MCA aneurysm present at the distal m1 segment at the bifurcation which is directed inferiorly.There is fetal origin of the right PCA with minor contribution from p1segment. A meningeal branch arises from the opthalmic artery.Left common carotid artery: No evidence for carotid stenosis on the basis of NASCET criteria. There is no evidence for carotid dissection.Left internal carotid artery: There is opacification of the left anterior, middle and posterior cerebral arteries. Venous and parenchymal phases were within normal limits. There is a left PCOMA aneurysm present which has a relatively small neck. The left PCOMA originates from the base of the aneurysm. The left A1 segment is dominant and supplies the left ACA and partly the right ACA. There is opacification of the left PCA which has a fetal origin with inflow of unopacified blood from the left p1 segment.There is a prominent anterior falx artery present.Left subclavian artery: No evidence for arteriovenous fistula. No evidence for vertebral dissection.Left vertebral artery: No evidence for aneurysm AVM or arteriovenous fistula. There is opacification of the cerebellar vasculature. The PCAs fill transiently the right p1 segment is very small. The left p1 segment does provide some supply to the left p2 segment and beyond.Right subclavian artery: No evidence for arteriovenous fistula. No evidence for vertebral dissection.Right vertebral artery: No evidence for aneurysm AVM or arteriovenous fistula. There is opacification of the cerebellar vasculature. The PCAs fill transiently the right p1 segment is very small. The left p1 segment does provide some supply to the left p2 segment and beyond.Intraprocedural angiograms:Serial arteriograms performed during aneurysm coiling demonstrate serial occlusion of the aneurysms using balloon remodeling. The balloon remained across the neck of the aneurysm throughout the procedure.Final RICA arteriogram :At the end of the procedure there is no opacification of the majority of the aneurysm with preservation of the PCOMA and anterior choroidal artery. There is opacification of the base of the aneurysm. There is occlusion of a branch of the parietoccipital artery with collateralization from the posterior parietal artery.Final LICA arteriogram :At the end of the procedure there is no opacification of the aneurysm with preservation of the PCOMA and anterior choroidal artery and no thromboembolic events.Repeat RICA arteriogram :At the end of the procedure there is no opacification of the majority of the aneurysm with preservation of the PCOMA and anterior choroidal artery. There is opacification of the base of the aneurysm. There is improved opacification of the right parietoccipital artery with partial reperfusion.Right common iliac artery: No contraindications to closure device.
1.6mm left PCOMA aneurysm2.4mm right PCOMA aneurysm3.2mm right MCA aneurysm4.50% stenosis of the right cavernous ICA5.Embolization of right PCOMA aneurysm with MRI compatible embolic occlusion coils and balloon assistance technique. There is a residual opacification of the base of the aneurysm6.Embolization of left PCOMA aneurysm with MRI compatible embolic occlusion coils and balloon assistance technique. 7.Small thromboembolic event of a branch of the right parietoccipital artery of the PCA was treated with mild anticoagulation. More aggressive treatment was not pursued based on risk/benefit assessment.8.Findings were discussed with Dr Awad and Dr Cueva at the end of the procedure.