Endovascular

Angioplasty and Coiling of
Ruptured Aneurysm with
Symptomatic Vasospasm: Technical
Case Report
Kenji Sugiu, M.D., Atsushi Katsumata, M.D., Yasuhiro Ono, M.D., Takashi Tamiya, M.D.,
and Takashi Ohmoto, M.D.
Department of Neurological Surgery, Okayama University Medical School, Okayama,
Japan

Sugiu K, Katsumata A, Ono Y, Tamiya T, Ohmoto T. Angioplasty
and coiling of ruptured aneurysm with symptomatic vasospasm:
technical case report. Surg Neurol 2003;59:413–7.
BACKGROUND

Treating a ruptured cerebral aneurysm during symptomatic vasospasm is very difficult. We describe the successful endovascular treatment of such a case and discuss its
efficacy.

reports suggest that surgical clipping did not affect
the development of vasospasm [8]. The embolization of intracranial aneurysms with Guglielmi detachable coils has been widely accepted, especially
for treating surgically difficult aneurysms [1,4]. Recent reports showed that the timing of endovascular treatment after acute bleeding did not affect

CASE PRESENTATION

A 34-year-old man had a sudden onset of severe headache. One week later, he was referred to our institute with
gradually progressing right hemiparesis and global aphasia. Cerebral angiography demonstrated severe vasospasm of the left internal carotid artery system and an
anterior communicating artery aneurysm. With the patient under general anesthesia, 90% occlusion of the aneurysm was achieved with detachable coils after successful dilatation of the spastic vessels. The patient had an
uneventful postoperative course and his neurologic
symptoms were improved. Seven months after the endovascular treatment, the enlarged neck remnant of the
aneurysm was successfully clipped without difficulty.
CONCLUSION

The simultaneous treatment of a ruptured aneurysm and
vasospasm with percutaneous transluminal angioplasty
and coils can produce a better outcome for the
patient. © 2003 Elsevier Inc. All rights reserved.
KEY WORDS

Angioplasty, cerebral aneurysm, detachable coil, endovascular treatment, vasospasm.

reating a ruptured cerebral aneurysm during
symptomatic vasospasm is very difficult
[5,6,9,11]. Conventional surgical treatment for such
cases may have poor results [6,10], although some

T

Address reprint requests to: Dr Kenji Sugiu, Department of Neurological
Surgery, Okayama University Medical School, 2-5-1 Shikata-cho, Okayama,
700-8558, Japan.
Received June 5, 2002; accepted September 28, 2002.
© 2003 Elsevier Inc. All rights reserved.
360 Park Avenue South, New York, NY 10010 –1710

Left ICA angiogram shows the AcomA aneurysm and
severe vasospasm of the distal ICA, the MCA, and
the ACA.

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0090-3019/03/$–see front matter
doi:10.1016/S0090-3019(03)00071-5

414 Surg Neurol
2003;59:413–7

The angiogram shows the flow arrest in the distal
ACA as the microcatheter becomes wedged in the
A1 segment. The arrow indicates the tip of the microcatheter inside the aneurysm. A distal portion of ICA has been
dilated by a balloon angioplasty.

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periprocedural morbidity rates or 6-month outcomes [1,12]. We describe the successful simultaneous treatment of a ruptured aneurysm and symptomatic vasospasm using percutaneous transluminal angioplasty and coils. This is the first case
report of successful endovascular treatment using
balloon angioplasty of approaching vessel followed
by coiling of a ruptured aneurysm.

Case Presentation
HISTORY
A 34-year-old man presented with headache, nausea, and vomiting and was admitted to another
clinic, where he was treated conservatively and had
complete resolution of the symptoms. One week
later, the patient gradually became drowsy and developed a right hemiparesis and global aphasia.
Computed tomography scans showed a subarachnoid hemorrhage in the interhemispheric fissure,
which was classified as Group 2 according to Fisher’s scale. The patient was then referred to our
institute for further treatment.

Sugiu et al

Skull X-ray demonstrates the balloon catheter in the
A1 segment during angioplasty. A tip of the balloon
catheter is at the orifice of the AcomA aneurysm, and
contrast material is in the aneurysmal sac.

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EXAMINATIONS
Upon examination, the patient was drowsy and had
right hemiparesis and global aphasia. Magnetic resonance imaging showed a small ischemic lesion in
the territory of the distal left anterior cerebral artery (ACA). Magnetic resonance angiography demonstrated an anterior communicating artery
(AcomA) aneurysm and narrowing of the bilateral
M1 segment of the middle cerebral artery (MCA).
Digital subtraction angiography was then performed. The initial left common carotid angiogram
showed the AcomA aneurysm with severe vasospasm of the left A1 segment of the ACA, the M1
segment of the MCA and the distal portion of the
internal carotid artery (ICA) (Figure 1). The right
carotid angiogram showed moderate vasospasm
from the distal ICA to the proximal M1 segment. The
right A1 segment was hypoplastic. No other aneurysm or spastic vessel was detected with the
4-vessel study.
INTERVENTION
We decided to treat the aneurysm via an endovascular approach and dilate the spastic vessels during the same procedure. With the patient under

PTA and Coil for Aneurysm with Vasospasm

The angiogram shows significant flow in the distal
ACA after successful angioplasty of the A1 segment.
The first coil was inserted in the aneurysmal sac.

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general anesthesia, a standard 6-Fr sheath was
placed in the right common femoral artery. A 6-Fr
guiding catheter (Guider Softip; TARGET Therapeutics/Boston Scientific, Fremont CA) was positioned
in the left ICA. Initially, only the distal portion of the
left ICA was dilated with a single-lumen balloon
dilatation catheter with a 3.0-mm diameter balloon
(FasStealth; TARGET Therapeutics/Boston Scientific). A microcatheter (Excelsior; TARGET Therapeutics/Boston Scientific) was then navigated into the
AcomA aneurysm. Despite severe vasospasm of the
left A1, which was an approaching vessel to the
AcomA aneurysm, the microcatheter was placed
into the aneurysmal sac without difficulty. However,
the flow of the ACA was arrested when the microcatheter wedged at the A1 segment (Figure 2). We
decided to dilate the A1 segment before embolizing
the aneurysm because the patient had a significant
ischemic lesion in the territory of the left ACA. After
successful angioplasty of M1, the FasStealth balloon
catheter with a 2.0-mm diameter balloon was advanced into the A1 segment. The balloon was sealed
with a microguidewire (Transend EX-14; TARGET
Therapeutics/Boston Scientific) and inflated using
gentle hand pressure, which successfully dilated

Surg Neurol 415
2003;59:413–7

Left ICA angiogram after treatment shows 90% occlusion of the aneurysm with successful dilatation
of the ICA, MCA, and ACA.

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the A1 segment (Figure 3). A significant dilatation of
the A1 segment was seen on the angiogram and an
Excelsior microcatheter was then advanced into
the aneurysmal dome. The flow of the distal ACA
was preserved (Figure 4). Four Guglielmi detachable coils were inserted into the aneurysm as a
frame. Then, four Detach coil systems were packed
into the frame of the Guglielmi coils, occluding 90%
of the aneurysm (Figure 5).
The patient had an uneventful postoperative
course and his neurologic deficits gradually diminished. He was discharged from the hospital one
month later with minimal right hemiparesis. A
follow-up angiogram 6 months after embolization
showed enlargement of the neck remnant. This remnant was successfully clipped 7 months after embolization without difficulty (Figure 6). The patient
is still in good clinical condition.

Discussion
Vasospasm is one of the most feared consequences
of aneurysmal subarachnoid hemorrhage. Treatment modalities for vasospasm have focused on
means to prevent or reverse the narrowing of ves-

416 Surg Neurol
2003;59:413–7

Sugiu et al

Left: Six-month follow-up angiogram shows enlargement of the neck remnant. It is square and seems likely to be
easily clipped. Right: Postoperative angiogram shows complete clipping of the aneurysm without removal of the
coil mass.

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sels and to increase the perfusion of ischemic brain
[2]. Early surgery is believed to prevent rebleeding
and is advantageous in treating vasospasm with
hypervolemia and hypertension [1]. However, some
patients still undergo delayed neurosurgical evaluation, presenting with an unsecured, recently ruptured aneurysm. Such patients pose a dilemma because the presence of vasospasm and an associated
ischemic deficit are contraindications to immediate
surgery. These patients may often progress to
stroke despite medical treatment and remain at risk
for repeated hemorrhage. In addition, medical treatment such as hypervolemic hypertensive therapy
can precipitate repeated hemorrhage from the unsecured aneurysm [7].
Recent reports have shown that the timing of
endovascular treatment after acute bleeding did
not affect periprocedural morbidity rates or
6-month outcomes [1,12]. Several reports indicate
that angioplasty is a safe and effective treatment for
symptomatic vasospasm, which is refractory maximum medical therapy, such as hyperdynamic hypervolemic therapy [2,3,7,9]. The international co-

operative study demonstrated that unfavorable
surgical results were associated with surgery performed 7 to 10 days after bleeding [6]. For the
patient having an unsecured ruptured aneurysm
with symptomatic vasospasm, endovascular treatment with angioplasty and coils seems to be
reasonable.
Our patient was referred to us when he suffered
from neurologic deficits, including right hemiparesis and global aphasia. Cerebral angiography revealed an anterior communicating aneurysm and
vessel narrowing in the left internal carotid artery
territory, which corresponded to his neurologic
symptoms. Because he had a severe headache a
week before, we believed he had severe vasospasm
after subarachnoid hemorrhage from the ruptured
anterior communicating artery aneurysm.
Initially, we planned to treat the aneurysm first
because angioplasty of the approaching vessel
would immediately increase blood flow into the aneurysm, possibly causing a fatal rerupture. However, the microcatheter became wedged in the A1
segment because of severe vasospasm. This com-

PTA and Coil for Aneurysm with Vasospasm

plication completely arrested flow in the distal ACA
territory, in which we suspected severe cerebral
ischemia. So we dilated the A1 segment following
angioplasty of the M1 segment. Balloon angioplasty
of small-caliber vessels, such as A1 or M2, is believed to be risky [12]. We used a standard microguidewire instead of a valvewire to seal the single
lumen-balloon. This maneuver increased the safety
of the procedure because minimum leakage of the
injected contrast material prevented the balloon
from over inflating.
Because of the severe vasospasm in this case, it
was difficult to precisely identify the neck of the
aneurysm. Therefore, we could not completely occlude the aneurysm. A residual neck appeared 6
months after treatment. This enlarged neck was
square and there was enough space to apply a clip.
We chose to clip rather than add coils to the neck
remnant, because the patient was young and had
nearly complete recovery from the initial symptoms
at that time. Endovascular coils are less invasive
and efficient in preventing rebleeding for a short
period, but this treatment is sometimes less effective than surgical clipping for the treatment of cerebral aneurysms in the long term follow-up [4].
Wanke et al reported combined endovascular
therapy of ruptured aneurysms and cerebral vasospasm using Guglielmi detachable coils and papaverin infusion [11]. To our knowledge, this is the first
case report of successful endovascular treatment
using both balloon angioplasty of the approaching
vessel and coiling for a ruptured aneurysm with
symptomatic vasospasm. We believe this technique
can provide a better outcome for the patient having
ruptured aneurysm at the spasm period.

The authors thank Hideki Wakimoto and Julie Yamamoto
for their editorial assistance.

REFERENCES
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COMMENTARY

This is an interesting single case of a ruptured
Acom aneurysm that was diagnosed during the period of sympotmatic vasospasm. Angioplasty of the
M1 and A1 segments was done before coiling the
aneurysm. A neck remnant noted postcoiling was
successfully clipped several months later. The patient recovered with residual right hemiparesis.
The authors claim that this is the first case of a
ruptured aneurysm in which coiling was done after
treatment of the vasospasm with balloon angioplasty. This is certainly not true; to speak only of
our series of ruptured aneurysms treated at the UIC
Medical Center, I remember at least one aneurysm
in a fenestration of the vertebrobasilar junction
with severe vasospasm in which angioplasty was
done in the same session, before coiling the
aneurysm.
It is difficult to argue with a single case, but the
risks of balloon angioplasty of the A1 segment before securing the aneurysm would be considered by
many neurosurgeons an indication to clip the aneurysm before sending the patient to neuroradiology
for balloon angioplasty to treat the vasospasm.
Gerard Debrun, M.D.
Interventional Neuroradiologist
Paris, France