Ruptured tiny intracranial aneurysm (RTIA), generally considered to be those of 3mm diameter or smaller, pose special technical challenges for endovascular surgeons. RTIA is particularly rare seen, representing approximately 1% of all intracranial aneurysms, and 0.5–2% of all ruptured aneurysms [1]. With the widespread adoption of three-dimensional (3D) rotational angiography, RTIA has been more frequently diagnosed, which has previously been considered to have a high rate of intraprocedural ruptures. It is a tough problem for neurosurgeons to choose appropriate operations because of more aggressive behaviors compared with saccular aneurysms and more occurred intra-operative complications [2].There are more probabilities to recur and rebleed in perioperative period. A previous meta-analysis that included only seven studies observed is relatively high complication rate, especially in terms of periprocedural rupture risk [3]. Electrocoagulation was applied to treat non-intracranial aneurysm in 19 th century, which could promote thrombosis in aneurysm. Youxiang Li was the first to cure intracranial aneurysms through electrocoagulation technology [4,5].
Aneurysms Image
All patients took intracranial computerized tomography (CT) to verify SAH before endovascular treatment. RTIA was confirmed by Digital Subtraction Angiography (DSA) in multi-angular rotation. Table 1 showed that there were eight patients with aneurysms located in posterior circulation and four patients with aneurysms located in anterior circulation. Common coiling method was difficult for this kind of aneurysms.
Operation
The endovascular treatment was carried out under general anesthesia and systemic heparinization to prevent arterial thromboses. The operator performed right femoral artery Seldinger puncture and put into a 6F artery sheath. After reshaping the tip of guidewire according to the angle between aneurysm and parent artery, we introduced the Traxcess 14 guidewire (Microvention, Columbia Aliso Viejo, USA) into the RTIA, advanced the microcatheter close to the pedicle, connected Traxcess to the Solitaire stent detachment system (ev3 Neurovascular, Irvine, USA) at about 4V and 1.0 mA electronic current, and passed current through it for 4 min, which was repeated for 3-5 times. 11 patients were carried out above procedure. But for the 6-year-old girl, we performed right femoral artery Seldinger puncture and put into a 5F artery sheath, DSA showed aneurysm was enlarged from 0.7×1.2mm(Fig 1a) to 3×3mm(Fig 1b) in two weeks, so that the risk of rebleeding increased. The RTIA was filled with 4 coils(Fig 1c) (Axium QC-2-6-Helix, NC-2-6-Helix, QC-1.5-4-Helix, APB-1-3 -HX-ES), then using jailing technique with a LVIS stent(3.5-15, Microvention, Columbia Aliso Viejo, USA). However there was a small cavity in the inflow tract, no more coils could be filled into it. The Nylon coil was in our expectation to promote thrombosis. One week later, unfortunately, the cavity was enlarged again(Fig 1d). The operator expected electrocoagulation would work effectively, which we carried out three times(Fig 1e), then the cavity disappeared completely and immediately.
Postoperative Treatment and Follow-up
After the procedure, heparin was neutralized naturally, and the patient returned to NICU after waking up under anesthesia. Analgesia, hypotensive medical treatment and nimodipine, a kind of anti-vasospasm medicine, were given; intracranial CT was performed again within one day after the procedure. It was recommended that follow-up DSA should be performed in the third month and at the end of the first year. Patients, who are unable to receive follow-up DSA, should be instructed to receive CTA and followed up by telephone review. The modified Rankin scale (mRS) was used to evaluate the prognosis of the patients. 0: No symptoms at all; 1: No significant disability: despite symptoms, able to carry out all usual duties and activities; 2:Slight disability: unable to perform all previous activities but able to look after own affairs without assistance; 3: Moderate disability: requiring some help but able to walk without assistance; 4: Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance; 5: Severe disability: bedridden, incontinent and requiring constant nursing care and attention; 6: Death (Table 1).