Lots of good stuff in this one case
Big SAH — classic ACOM pattern
ACOM aneurysm confirmed. Known remote left ICA occlusion — ACOM does most of reconstitution. A setup for future vasospasm disaster…
It is critical not to compromise the ACOM here as entire left hemisphere depends on it
We try the web — the smallest one is too big… it really needs to be perfect (white outline below), with nothing sticking into the ACOM — the whole left side depends on it. Should have thought of that more… waste of a good WEB — took it out.
Balloon-assisted coiling — still an art u need to know. This is a transform 3×10
Post — a very nice balloon-assisted result. See that flat neck in top images — that’s ACOM preservation…
At the end, we get beautiful bilateral venous phase VR stereo images
Five days later — spasm. Gets IA verapamil. No balloon. Guess what — next day she is back for more… Look at that starving left hemisphere… Anyone who thinks IA anything will save the day? I hope you don’t. Vasospasm is a form of stroke — if you act quickly it helps. If you wait until the morning, or until they have their HHH heart attack, then it doesn’t.
This needs mechanical angioplasty
Working projection — its mirror image from above — just to keep your mind flexible
Ipsilateral balloon — this is the easy part
OK — now what? she really needs that left A1 plastied still
Easier said than done. No 014 wire would make that turn… We did however get into the left A2, which needs some also
Something strange here, no? Why this waist (narrowing) on the balloon?
We ultimately managed to get into left A1/MCA with a 0.08 Hybrid
The slight inconvenience is that we have a Transform balloon… what’s the problem with that combination?
No problem — a 2/3 contrast 1/3 saline 3 cc syringe injection of the balloon will transiently expand it — find the equilibrium point to keep it up just the right amount and any wire is good for transform angioplasty
Much better now — remember to look at venous phase to see if perfusion is symmetric and adequate — see BTO page for more info
She did ok in the end — this is 3 weeks later. Still has some of that hematoma edema. Drain is out too — see that little tract hole in upper left image?
So, what was the issue with that balloon shape? See Part 2 to find out…