J Cerebrovasc Endovasc Neurosurg.  2017 Mar;19(1):48-51. 10.7461/jcen.2017.19.1.48.

Treatment of Cerebral Vasospasm in an Infant Using a Modified Dotter Technique

• Snelling B
• Sur S
• Shah SS
• Peterson E

• KMID: 2377626
• DOI: http://doi.org/10.7461/jcen.2017.19.1.48

Abstract

An 8-month old female presented with spontaneous subarachnoid hemorrhage and was treated successfully with endovascular coil embolization of the ruptured aneurysm. Transcranial Doppler ultrasound performed four days later demonstrated middle cerebral artery (MCA) velocities greater than 350 cm/sec on the right and greater than 200 cm/sec on the left, despite medical management. The patient demonstrated no focal neurological deficits, though examination was limited by our patient's sedation and intubation. Angiography revealed severe vasospasm of the supraclinoid internal carotid and MCA territories, bilaterally. The vasospasm was refractory to the administration of intra-arterial verapamil. Balloon angioplasty was attempted, but the device could not be advanced safely due to the small size of the patient's vessels and the stiffness of the device. A microcatheter (0.0165" diameter) was advanced over a J-shaped soft microwire (0.014" diameter) to perform mechanical angioplasty in the internal carotid artery and MCA vessels bilaterally. Dramatic improvement was seen angiographically and on transcranial Doppler, and no complications were seen.

Keyword

Aneurysm; Angioplasty; Dotter technique; Pediatric; Cerebral vasospasm

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Angiography
Angioplasty
Angioplasty, Balloon
Carotid Artery, Internal
Embolization, Therapeutic
Female
Humans
Infant*
Intubation
Middle Cerebral Artery
Subarachnoid Hemorrhage
Ultrasonography
Vasospasm, Intracranial*
Verapamil
Verapamil

Figure

• 

  Fig. 1 Angiography three days post aneurysm coiling revealed bilateral vasospasm of the supraclinoid ICA, ACA, and MCA territories. The vasospasm was greater than 60%, when compared to her initial angiogram. ICA = internal carotid artery; ACA = anterior cerebral artery; MCA = middle cerebral artery.

• 

  Fig. 2 The supraclinoid ICA and MCA were mechanically dilated bilaterally using a Marathon™ microcatheter (0.0165" diameter), which advanced over a J-shaped 0.014" soft Mirage™ microwire (0.014" diameter). ICA = internal carotid artery; MCA = middle cerebral artery.

• 

  Fig. 3 Post-procedural angiography revealed dramatic improvement as the proximal MCA M1 segment diameters increased to 1.0 in the right and 1.2 mm in the left. MCA = middle cerebral artery.

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