Spontaneous rupture of cerebral aneurysm after thrombectomy in a case of acute ischemic stroke with proximal occlusion
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LETTER TO THE EDITOR
Spontaneous rupture of cerebral aneurysm after thrombectomy in a case of acute ischemic stroke with proximal occlusion E. Levecque1 · O. Cornet2 · D. Brisbois2 · P. Reginster3 · P. Desfontaines1 Received: 7 March 2020 / Accepted: 19 September 2020 © Belgian Neurological Society 2020
Background and aims Unruptured cerebral aneurysm may be hidden by a proximal occlusion in some cases of acute ischemic stroke. Around 1–5% of the adult population has an intracranial aneurysm and according to the International Study of Unruptured Intracranial Aneurysms 30% of these are middle cerebral artery (MCA) aneurysms. The major complication associated with intracranial aneurysms is aneurysm rupture resulting in subarachnoid haemorrhage [3]. Treatment of patients with acute ischemic strokes using mechanical thrombectomy devices has yielded both higher rates of revascularization as well as superior clinical outcomes when compared with medical therapy with intravenous thrombolytics alone [2].
Method and results On December 20, 2017, a 78-year-old woman was transferred from a primary stroke care centre to our comprehensive stroke centre because of sudden left hemiplegia and hemianopia. The initial obtained NIHSS was 14. The CT angiography performed in the emergency department shows a cerebral thrombus in the right middle cerebral artery (M1) without ischemic injury and with good collaterals. Since the onset of symptoms was less than 4.5 h IV thrombolysis was performed, and she was immediately transferred to the arteriography room for thrombectomy. * E. Levecque [email protected] 1
Neurology‑ Comprehensive Stroke Center, Centre Hospitalier Chrétien, LIEGE, Belgium
2
Interventional Neuroradiology, Centre Hospitalier Chrétien, LIEGE, Belgium
3
Centre Hospitalier Chrétien, Neuroradiology, LIEGE, Belgium
The anesthesiologist who was present on the spot immediately carried out a general anesthesia. The first opacification of the sylvian artery show an M1 stop just after a proximal permeable ascending branch. During catheterism, the Avigo microguide wire spontaneously found a descending branch at the same level. After the first Solitaire stent retriever passage, the opacification shows, the origin of the descending branch with a residual proximal clot and a large neck 5 mm aneurysm of the Sylvian bifurcation (Fig. 1). Unfortunately a piece of the clot migrate and occlude the proximal part of the acsending branch previously permeable. A second passage of the stent retriever permit a total recanalisation of the descending branch (Fig. 2). A third passage was decide for recanalisation of the ascending branch. During catheterisation with the Avigo guide wire, the proximal part of the guide wire navigate in the occlude ascending branch than his middle part kink and a loop of the wire enter and rupture the aneurysm (Fig. 3). Important extravasation was demonstrate by selective opacification. A cerebral CT angiography performed in the arteriography room shows a significant subarachnoi
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