J Cerebrovasc Endovasc Neurosurg.  2015 Jun;17(2):108-112. 10.7461/jcen.2015.17.2.108.

Endovascular Treatment in Ruptured Middle Cerebral Artery Dissection Preservation of Arterial Continuity

• Nam DH
• Park SK

• KMID: 1879342
• DOI: http://doi.org/10.7461/jcen.2015.17.2.108

Abstract

Rupture of spontaneous dissecting aneurysms of the middle cerebral artery (MCA) is rare and its etiology remains obscure, although the risk of rebleeding is greater than with saccular aneurysms. Most reports concerning the treatment of a ruptured dissecting aneurysm of the anterior circulation involve surgical trapping or wrapping. Here, we report on a case of an MCA dissecting rupture treated with endovascular procedures. A 22-year-old female presented with sudden stuporous mental change following severe headache and left side hemiparesis. A computed tomography scan showed a diffuse subarachnoid hemorrhage and diffusion MR showed diffusion restriction at the right putamen and internal capsule. A 3-hour follow-up digital subtraction angiography (DSA) showed a dissecting aneurysm, which was not seen on an initial DSA. A stent assisted coil embolization was performed and double stents were applied to achieve flow diversion effects. A small remnant area of the dissecting aneurysm had disappeared at 60-day and was not observed on 12-month follow-up DSA.

Keyword

Dissecting aneurysm; Middle cerebral artery; Flow diversion; Stent assisted coil embolization

MeSH Terms

Aneurysm
Aneurysm, Dissecting
Angiography, Digital Subtraction
Diffusion
Embolization, Therapeutic
Endovascular Procedures
Female
Follow-Up Studies
Headache
Humans
Internal Capsule
Middle Cerebral Artery*
Paresis
Putamen
Rupture
Stents
Stupor
Subarachnoid Hemorrhage
Young Adult

Figure

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  Fig. 1 Initial radiologic images. (A) Plain computed tomography (CT) scan shows diffuse subarachnoid hemorrhage. (B) CT angiogram shows no definite saccular aneurysm. (C) First digital subtraction angiogram (DSA) shows no definite saccular aneurysm except for a slight irregular dilatation of the posterior aspect of the right proximal M1. (D) Diffusion-wighted MR image shows diffusion restriction in the right putamen and posterior part of the internal capsule.

• 

  Fig. 2 (A, B) Follow-up digital subtraction angiogram (DSA) (3 hours after the previous DSA) shows saccular aneurysmal dilatation at the postero-inferior aspect of the right middle cerebral artery (M1), which is not seen on the previous angiogram and is observed at the same location of slight irregular dilatation of M1 on the previous angiogram. The aneurysm was measured as 3.0 × 2.3 mm in size with a neck size of 2.7 mm. (C, D) Coil embolization and double stent deployment were performed.

• 

  Fig. 3 Follow-up digital subtraction angiogram (DSA) after stent-assisted coil embolization. (A) The first follow-up angiogram performed 7 days after intervention shows no definite interval change. (B) The fourth follow-up angiogram, 30 days after intervention, shows the disappearance of the previous dilatation of the aneurysmal neck. Angiograms (C and D) one year after intervention, shows no further aneurysmal dilatation around the coiled site. The middle cerebral artery flow is completely separated from the coils and stents on angiography, as a result of successful healing and endothelialization.

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