Aneurysm come in all shape and sizes and at all locations.

This one was in a 42 years old female patient with Grade I SAH and a ruptured right PcomA aneurysm.

The anatomy was odd with a bulbous, rather blister like proximal part, then a narrowing, then the body, again a narrowing then a teat like portion. The Pcom, of course, had to arise from the aneurysm; specifically it came at the site of first narrowing mentioned.

The aneurysm was directed laterally and posteriorly and had a curved structure rather.

The proximal bulbous portion measured 2.67 mm in diameter with equal neck and the distal narrower portions 2 mm.

So, I used an Echelon and Xpedion –ten system- to access the aneurysm.

Then i was in a fix as to how to go about fixing the aneurysm.

I put in a 2x6 3D AXIUM in the mid part of the aneurysm beyond the Pcom origin. The coil loops did try to go in the distal teat but somehow the entire coil could be fit in there.

Angio showed complete cessation of flow within that portion, with contrast stasis in the teat and the Pcom stayed patent.

However in the native images, still some space appeared within the coil mesh, so I took an AXIUM 2x4 Helix coil and pushed in.

The loops went into the first coil and then started to come into the proximal portion. Somehow, the loops in this part stayed horizontal thus restructuring the inflow zone and contrast flowing into the pcom.

But the last loop could not be fit in and kept pushing the microcatheter tip into the arterial lumen.

So I left the procedure at that point and put my hands up.

The patient is fine, and we all are happy, but do not know what this anueurysm was ot how best to treat it.

My surgeon too told he would have clipped in the midpart  so the result would have been same, or rather bad as this looked to me like an infundibulum which had ruptured and the distal portion to me was nothing but a pseudoaneurysm.

I am keeping my fingers crossed. let’s see….

Heparin dosing is associated with diffusion weighted imaging lesion load following aneurysm coiling: Background and purpose
Diffusion weighted imaging (DWI) may be used to evaluate post-coiling ischemia. Heparinization protocols for cerebral aneurysm coiling procedures differ among operators and centers, with little literature surrounding its effect on DWI lesions. The goal of this study was to determine which factors, including heparinization protocols, may affect DWI lesion load post-coiling.
Materials and methods
A review of 135 coiling procedures over 5 years at our centre was performed. Procedural data including length of procedure, number of coils used, stent or balloon assistance and operators were collected. Procedures were either assigned as using a bolus dose (>2000 U at any one time) or small aliquots of heparin (≤2000 U). Postprocedure DWI was reviewed and lesions were classified as small (< 5mm), medium (5–10 mm) or large (>10 mm). The cases were then classified into group 1 (≤5 small lesions) or group 2 (>5 small lesions or ≥1 medium or large lesion). Multivariate regression of the procedural variables for the two groups was calculated. A p value of <0.05 was considered significant.
Results
There were 78 procedures in group 1 and 57 procedures in group 2. Patients who received small aliquots (n=37) versus boluses of heparin (n=98) intraprocedurally had significantly greater frequency and size of DWI lesions (p=0.03). None of the other procedural variables was found to impact on lesion load.
Conclusions
More substantial DWI lesions were associated with small aliquots of heparin dosage compared with bolus doses. Heparin boluses should be preferentially administered during aneurysm coiling.

• 49 yrs, M
• Seizures on the morning of admission
• Vitals stable
• No focal deficit
• A CT done at admission showed SAH with flocculent surface hematoma in the left anterior frontal region…significantly there was no blood in the basal cisterns
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• NCCT at admission
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• Enlarged images of the NCCT
• A cerebral DSA was done which showed thrombosis of anterior part of the superior sagittal sinus, partial thrombosis of the inferior sagittal sinus with hypoplastic left transverse and sigmoid sinuses
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• Right ICA angiogram
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• Left ICA angiogram
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• Left and right vertebral angiogram
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• Right middle meningeal had anomalous origin from right petrous ICA
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• Left ECA angiogram showed blush from the middle meningeal artery in the region of the thrombosed superior sagittal sinus

Patient was put on heparin after this

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• NCCT next morning showed significant resolution of the SAH.
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• Enlarged images of the NCCT
• The patient had an uneventful recovery and was discharged in a stable condition, on Warfarin.