Case Report Stent-Assisted Re-embolization of a Recanalized Ruptured AcomA Aneurysm

Hospital: Hospital General Universitario Dr. Balmis Department: Neurosurgery Sex: Female Age: 54

Sudden onset of severe headache and a generalized seizure.

• Type 2 Diabetes Mellitus (DM2)
• Hypertension (HTA)
• No known dyslipidemia
• No toxic habits
• Previous subarachnoid hemorrhage (SAH) from ruptured anterior communicating artery (AcomA) aneurysm, initially treated with endovascular coiling
• Usual treatment:
  1. Omeprazole
  2. Acetylsalicylic acid (ASA)
  3. Clopidogrel
  4. Levetiracetam

Initial status (ICU admission):

• GCS: 15
• TA: 164/64 mmHg
• SatO2: 97% with low-flow nasal cannula
• No cranial nerve deficits
• Mobilizes all four limbs on command
• No meningeal signs
• No focal neurological deficits
• Mild bruising at femoral puncture site
• Preserved popliteal pulse; absent pedal pulse on the right side

• Blood Gas: Normal (pH 7.38, pCO₂ 40.8 mmHg, pO₂ 109 mmHg)
• Labs:
  1. Glucose: 157 mg/dL
  2. Creatinine: 0.62 mg/dL
  3. CRP: 9.88 mg/dL
  4. Hb: 11.5 g/dL
  5. Platelets: 170,000/μL
  6. APTT ratio: 1.77
  7. Thrombin time: 34.3 s
• Angiography:
  1. Residual perfused sac of 3 mm in the AcomA
  2. Preferential filling from the left ACA
  3. Indicated for re-embolization with stent-assisted coiling

Technique:

• General anesthesia and systemic heparinization (6000 UI)
• Right femoral artery access
• Catheters: Simmons 2, Envoy, Neuroslider 17
• Stent: ACCERO 2.5 x 20 mm
• Coils: Numen Microfill (3x6mm, 2x2cm), Microfinish (1.5x2mm)
• Closure: AngioSeal 8F
• Intraoperative Event: Coil migration into ACA2 left → Partial stent deployment (70%) → Additional coils inserted → Final release of stent bridging ACA1 to ACA2
• No intraoperative complications

• Hemodynamically stable, no vasopressors
• No neurological deterioration
• Normal lactate, bicarbonate, and blood gases
• No fever or infection
• Normal renal function and electrolytes
• Tolerated oral intake
• Femoral puncture site stable

• Transferred to Neurosurgery ward
• No new focal neurological deficits
• Stable clinical course
• Tolerated oral diet
• Normal bowel and bladder function
• Imaging follow-up: No complications
• Discharged in good general condition

• Ruptured anterior communicating artery aneurysm (AcomA)
• Subarachnoid hemorrhage (SAH), aneurysmal
• Recanalized aneurysm
• Re-embolization with stent-assisted coiling
• Seizure secondary to SAH

• ASA 100 mg daily
• Clopidogrel 75 mg daily (pending approval)
• Enoxaparin 40 mg SC daily × 10 days
• Amlodipine 5 mg daily
• Levetiracetam 500 mg every 12h
• Paracetamol 1000 mg every 8h × 10 days
• Metamizole 575 mg every 8h × 10 days

• Avoid strenuous physical activity
• Mobilize with assistance
• Follow-up in outpatient neurosurgery clinic