case_images: PMC4078451_01
case_images: (a) Head CT scan showing diffuse and thick SAH on admission. (b) 3D image of left IC angiography showing a paraclinoid aneurysm. (c) The aneurysm was successfully obliterated with coiling. (d) Head CT scan on day 3 showing most of the SAH was washed out
case_images: SNI-5-61-g001.jpg
case_images: PMC4078451_01_SNI-5-61-g001.jpg
case_images: F1
case_images: A 55-year-old right-handed female was admitted to the intensive care unit (ICU) for an SAH caused by the rupture of a left internal carotid artery (ICA) paraclinoid aneurysm [Figure 1]. Under general anesthesia, the left ICA paraclinoid saccular aneurysm was successfully treated by endovascular coil embolization with a stent assist (Neuroform EZ ; Stryker Neurovascular, Fremont, CA) [Figure 1]. Urokinase (12000 units) irrigation from a lumber drainage on days 1 and 2 cleared the thick SAH [Figure 1] in order to prevent forthcoming vasospasm.
case_images: Neuroimages obtained at the onset of deafness. (a) MR angiogram showing severe vasospasm in the right MCA and moderate vasospasm in the left MCA. (b) DW image showing high signal intensity at the right insular cortex and the left superior temporal gyrus, indicating acute infarction due to vasospasm. (c) ASL images show bilateral superior temporal gyri
case_images: SNI-5-61-g002.jpg
case_images: PMC4078451_01_SNI-5-61-g002.jpg
case_images: F2
case_images: The MR angiograms demonstrated severe vasospasm in the right middle cerebral artery (MCA) and moderate vasospasm in the left MCA [Figure 2]. The diffusion-weighted (DW) images revealed high signal intensity at the right insular cortex and left superior temporal gyrus, indicating acute infarction due to vasospasm [Figure 2]. ASL showed mild hypoperfusion in both temporal lobes including the auditory cortex [Figure 2].
case_images: (a) Right ICA angiography showing spasm in the right MCA. (b) A microcatheter was advanced to the right M1 and papaverine was administered from there. (c) The right MCA spasm improved after the papaverine administration. (d) Conservative air conduction audiogram obtained at the onset of deafness, showing severe hearing loss bilaterally. After the endovascular treatment, her hearing ability became normal level bilaterally
case_images: SNI-5-61-g003.jpg
case_images: PMC4078451_01_SNI-5-61-g003.jpg
case_images: F3
case_images: Immediate conventional catheter digital subtraction angiography was done and it showed severe vasospasm in the right MCA [Figure 3] and moderate vasospasm in the left MCA. A microcatheter (Tangent ; Stryker Neurovascular, Fremont, CA) through a 6F guiding catheter (Envoy ; Cordis, Miami Lakes, FL) over a 0.014-inch guidewire (Transend EX ; Stryker Neurovascular, Fremont, CA) was advanced to the right M1 [Figure 3]. This resulted in transient angiographic improvement [Figure 3]. She could hear the lowest level of the device bilaterally [Figure 3].