• History and Examination 
     
    History
    •60s year old woman with prior SAH with clipping and VP shunt placement in 1990
    •Now presents with Hunt Hess grade 3, Fisher score 3/4 SAH
    Exam
    •Lethargic, confused, left CN 6 palsy, full strength and intact sensation.
     

    Figure 1

     

    Figure 2

    Figure 3

     

    Figure 4

    1. What is the cause of her left CN6 Palsy?

    2. You tap her right occipital VP shunt and there is good proximal flow, and shunt series shows no disconnection. What would be your next step in management?

     

    3 .How would you treat the ruptured aneurysm?

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Comments

    • Nice case
    • great case
    • great case
    • Cannot answer Q#2 since it does not give ability to confirm is the shunt is working since it gives no info regarding distal function/runoff
    • It seems strange for me when I read Fisher score 3/4. If there is blook (clot) inside the 4th ventricle, we should classify as Fisher 4, right?
    • Interesting case
    • It would be nice to know if the after you remove suction does the fluid in the line drain off during shunt tap. also does the shunt valve pump and refill. also you can access occluder valves when pumping to asses patency of distal tubing.
    • Coiling/stent assisted coiling not yet developed in my country.
    • EVD and figure out why it is obstructed after vp shunt.
    • I would prefer to change the valve, as valve malfunction is the commenest cause!!! Question 2
    • Good case
    • Great

    Case Explanation:

    We thought that the left CN6 palsy was due to increased ICP from hydrocephalus, so we tapped the existing right occipital VP shunt which demonstrated good flow and the shunt series demonstrated no disconnection. However, there is clearly ventriculomegaly and along with her left CN 6 palsy, she was lethargic and confused. A number of options are available, but we chose to just simply place a right frontal EVD which produced CSF under pressure.

    As for treatment of the aneurysm, there are a number of options. We have found in our experience, re-do aneurysm clipping to be complex and challenging.  There is also data from the BRAT Trial that posterior circulation aneurysms, in particular PICA aneurysms, have poorer outcomes with clipping1.  Therefore we chose to treat the aneurysm endovascularly.  There is suggestion of increased risk of hemorrhagic complications when using dual antiplatelet medications for stenting or flow diversion in the setting of SAH2,3.  We have been successful in our experience in treating complex wide-neck aneurysms with staged coiling followed later by 2nd stage treatment with a stent or flow diversion when dual antiplatelet medications can be used after recovery from the SAH4.  Therefore, we initially performed balloon-assisted coiling and coil occluded the dome and the daughter sac which is likely the source of rupture, then brought her back after recovery from her SAH for 2nd stage treatment with a flow diversion stent when we felt it was safe to put her on dual antiplatelet medications.  We were concerned about the left PICA coming out of the base of the aneurysm, but she did very well, and the left PICA remained patent. 

    References:

    1.The Barrow Ruptured Aneurysm Trial: 6-year results. Spetzler RF, McDougall CG,Zabramski JM, Albuquerque FC, Hills NK, Russin JJ, Partovi S, Nakaji P, WallaceRC. J Neurosurg. 2015 Sep;123(3):609-17. doi: 10.3171/2014.9.JNS141749. Epub2015 Jun 26. PMID: 26115467

    2.Intracranial hemorrhage associated with stent-assisted coil embolization of cerebral aneurysms: a cautionary report. Tumialán LM, Zhang YJ, CawleyCM, Dion JE, Tong FC, Barrow DL. J Neurosurg. 2008 Jun;108(6):1122-9. doi:10.3171/JNS/2008/108/6/1122. PMID: 18518714
    3.Treatment of intracranial aneurysms with the Enterprise stent: a multicenter registry.Mocco J, Snyder KV, Albuquerque FC, Bendok BR, Alan S B, Carpenter JS,Fiorella DJ, Hoh BL, Howington JU, Jankowitz BT, Liebman KM, Rai AT, Rodriguez-Mercado R, Siddiqui AH, Veznedaroglu E, Hopkins LN, Levy EI. JNeurosurg. 2009 Jan;110(1):35-9. doi: 10.3171/2008.7.JNS08322. PMID: 18976057
    4.Intentional partial coiling dome protection of complex ruptured cerebral aneurysms prevents acute rebleeding and produces favorable clinical outcomes. Waldau B,Reavey-Cantwell JF, Lawson MF, Jahshan S, Levy EI, Siddiqui AH, MoccoJ, Hoh BL. Acta Neurochir (Wien). 2012 Jan;154(1):27-31. doi: 10.1007/s00701-011-1214-z. Epub 2011 Nov 9. PMID: 22068717
     

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