Coiling, Ruptured Left Pcom Aneurysm
H&P
- HPI:
- Presented to ED
- Two days of left eye pain, headache, blurry vision
- PE: left ptosis, anisocoria (L>R), EOMi, others normal
Imaging
CT Head without Contrast - Axial and Coronal
Left posterior clinoid process hyperdensity (left). Trace intraventricular hemorrhage at right posterior horn (right).
CTA Head - Axial, Coronal, and Sagittal
A left posterior communicating artery (Pcom) aneurysm is indicated on the CTA from outside hospital (not good quality, thick cuts).
DSA and Embolization
- Access: right common femoral artery
- 6F 25 cm sheath
- 6F 90 cm MPD Envoy DA
- 4F 100 cm Glidecath, vert tip
- 0.035'' 150 cm Glidewire
- 150 cm SL-10, straight tip
- 0.014'' 200 cm Synchro2
- 3D eV3 Axium Prime 3.5 mm x 6 cm coil
- 3D eV3 Axium Prime 3 mm x 4 cm coil
- HX eV3 Axium Prime 2.5 mm x 8 cm coil
DSA - Left ICA Injection, PA and Lateral
DSA - Magnified Left ICA Injection, PA and Lateral
DSA 3D Reconstruction - Aneurysm Measurements
DSA 3D Reconstruction - ICA Measurements
DSA - Embolization Working Angles, PA and Lateral
DSA - 1st Coil in Place
DSA, Post-1st Coil - Left ICA Injection, PA and Lateral
DSA - 2nd Coil in Place
DSA, Post-2nd Coil - Left ICA Injection, PA and Lateral
DSA - 3rd Coil in Place
DSA, Post-3rd Coil - Left ICA Injection, PA and Lateral
DSA, Post-Coil Embolization - Left ICA Injection, PA and Lateral
Control DSA, Post-Coil Embolization - Left ICA Injection, PA and Lateral
Post-Operative Course
- No new neurological deficits
- Continued Nimodipine and Keppra
- Left ptosis improved on postoperative day (POD) 1
- Anisocoria persisted
- Transferred to floor on POD6
- Discharged on POD10
Discussion
- Ptosis improved thanks to the amelioration of the pulsatile compression from the aneurysm on the CN III.
- The parasympathetic fibers are at periphery which is first injured by the mechanical compression from the aneurysm -> persistent anisocoria.
- Flow diverter is another option, however, not ideal considering the patient's recent rupture of the aneurysm.
Reference
