Temporary Semi-Jailing Technique for Coil Embolization of Wide-Neck Aneurysm with Small Caliber Parent Artery Following Incomplete Clipping
A 41 years old man with seizure like movement was admitted to our hospital. He had a history of hypertension treatment for 3 years. On neurologic examination, the patient was drowsy (Glasgow Coma Score : E3, V4, M6). He showed 2/5 and 3/5 strength in the right and left lower extremity and 5/5 strength in both upper extremities. Hunt-Hess classification was 3, and Fisher grade was 4. Initial computed tomography (CT) revealed the presence of a subarachnoid hemorrhage and aneurysm in the A1 segment of the anterior cerebral artery (ACA) with inferior and superior projection. The patient was treated with surgical clipping and upper extremity weakness was fully recovered. But superior and posterior portion of the aneurysm remained on follow-up transfemoral cerebral angiography (). We decided to treat the remnant aneurysm using an endovascular modality.\nThe patient was placed on 300 mg of clopidogrel, 100 mg of aspirin one day before embolization and 75 mg of clopidogrel, 100 mg of aspirin on the day of operation. Treatment was performed under general anesthesia and via the transfemoral approach. Under full heparinization, a 6-French guide catheter was placed in the right internal carotid artery. A Prowler Select Plus microcatheter (Cordis neurovascular, Miami, FL, USA) was navigated across the aneurysm neck over a 0.014'' microguidewire. An Excelsior SL-10 microcatheter (Striker, Fremont, CA, USA), for coil delivery were carefully navigated to the aneurysm. Through Prowler Select Plus microcatheter, a 4.5×22 mm Enterprise stent advanced and readied for deployment. The stent was partially deployed (up to 30-60% of its length) bridging the aneurysm's wide neck. Subsequent coil packing (4 coils, sizes ranging from 2×30 mm to 1.5×10 mm, Micrus Endovascular) resulted in subtotal occlusion of the aneurysm without coil herniation through the stent struts into the parent lumen (). Whenever each coil was inserted, the stent was partially recaptured into the Prowler Select Plus microcatheter then the SL-10 microcatheter was removed for angiography to ensure safety of the small caliber parent artery (). A final control angiogram confirmed aneurysm occlusion, and preservation of the blood flow within the territory including A1 segment (). The patient awoke without neurological deficit. One day follow-up CT showed no abnormal low density in ACA territory. Follow-up transcranial doppler ultrasonogram showed patent blood flows of bilateral ACAs (right : left, mean=78 : 74, systolic 118 : 104, diastolic=54 : 55). Further clinical and neurological follow-up examinations are planned after 1 and 3 months, and digital subtraction angiogram (DSA) follow-up are planned after 6 months.