Anterior Communicating Artery Aneurysm: Incidental AcomA Aneurysm, pCONus-assisted Coil Occlusion, Intracerebral Hematoma due to Hyper-response on Aspirin and Clopidogrel

Abstract

A small wide-necked incidental aneurysm of the anterior communicating artery (AcomA) was found in a 65-year-old woman, who was healthy apart from a history of mild arterial hypertension. After discussing all potential management options with the patient and her husband, the final decision was taken to treat the aneurysm by coil occlusion, assisted by a pCONus stent (phenox). The patient was prepared for the stent implantation with dual platelet function inhibition through acetylsalicylic acid (ASA) and clopidogrel. The endovascular procedure was carried out as intended. A pCONus_mini was implanted via the left internal carotid artery and the left A1 segment, with its distal end level with the neck of the AcomA aneurysm, followed by the coil occlusion of the aneurysm. The following morning after this procedure, the patient became aphasic and observed a visual field cut to the right. MRI showed a 5.5 × 3.5 × 3.5 cm intracerebral hematoma in the left temporal and occipital lobe, which was managed conservatively. Multiplate tests (Roche Diagnostics) revealed a hyper-response to the ASA and clopidogrel, which required a monitored dosage reduction of both medications. The phenomenon of hyper-response to medical antiaggregation and the management of this condition are the main topics of this chapter.