Tmatthews
Contributor
Please help!
Doctor reported:
36200
61624
75894
36222x2
36224x1
36228x1
75898x11
75896
I think:
61624
36222x1
36224x1
36228x1
75898 x ?
75896
ICD Codes / Adm.Diagnosis: 437.3 / angio Cerebral aneurysm without rupt
Examination: XA CAROTID/CERV BI W CATH SI -
Accession No:
Reason: aneurysm
REPORT:
CLINICAL INDICATION: Anterior communicating artery aneurysm for evaluation
and potential endovascular treatment.
CONTROL ANGIOGRAMS: 12
COMPLICATIONS: None.
GENERAL ANESTHESIA: Pre-procedure evaluation confirmed that the patient was
an appropriate candidate for general anesthesia. Adequate anesthesia was
maintained during the entire procedure by the anesthesia team. Vital signs
and pulse oximetry were monitored and recorded by the anesthetist throughout
the procedure and the recovery period. The flow sheet was placed in the
medical record including the medications and dosages used. No immediate
anesthesia related complications were noted.
PRE-PROCEDURE: The patient was seen and examined. The chart and images were
reviewed. I had a lengthy discussion with the patient and/or their family
regarding the disease process, as well as potential treatment options, which
include medical management, surgical treatment, or endovascular treatment.
The risks, benefits, and alternatives to the procedure were explained to the
patient and/or the family, and written informed consent was obtained.
PROCEDURE: A Time-Out was performed prior to the procedure to confirm the
patient's identity and the appropriate procedure. The patient was placed
supine on the angiographic table, and the right groin was prepped and draped
in the usual sterile manner. Using a 5 French micropuncture set, the right
common femoral artery was punctured and cannulated, and a 6 French arterial
sheath was placed over a guidewire. The sheath was attached to continuous
heparinized saline flush. A catheter was placed through the sheath and
advanced over a Terumo guidewire into the aortic arch.
Selective catheterization of the following blood vessels was performed (see
below). At the end of the procedure, hemostasis was achieved. Hemostasis was
achieved through closure device placement. Following hemostasis, with no
hematoma, the site was cleaned and dressed with sterile dressing.
Intravenous heparin was intermittently administered throughout the
procedure, monitored with serial ACT measurements, with the ACT maintained
at 250-300. The heparin was not reversed following the procedure.
DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC
ARTERIOGRAMS:
LEFT SUBCLAVIAN ARTERY: The catheter was advanced into the left subclavian
artery. DSA imaging was performed in the AP and lateral projections, with
imaging over the cervical region. The left subclavian artery demonstrates
slight atherosclerotic disease, with no stenosis.. The left vertebral artery
is widely patent at its origin and normal in caliber throughout its cervical
course. The thyrocervical and costocervical trunks are widely patent. The
internal mammary artery is widely patent at its origin.
LEFT VERTEBRAL ARTERY: The catheter was advanced into left vertebral
artery. DSA in the AP and lateral views of the intracranial circulation was
performed. The left vertebral artery is normal in caliber and contour. The
left PICA is normal in caliber and contour. Excellent cross-filling of the
V4 right vertebral artery demonstrates normal caliber and contour of the
right PICA. The basilar artery is normal in caliber and contour. The
bilateral anterior inferior cerebellar and superior cerebellar arteries are
normal caliber and contour. The left posterior cerebral artery is absent.
The P1 segment of the right posterior cerebral artery is hypoplastic, with
flash filling of the right posterior cerebral artery territory from this
injection. No stenosis, occlusion, dissection, aneurysm, or vascular
malformation. Capillary phase imaging demonstrates normal parenchymal
opacification and arteriovenous transit time. The main intracranial venous
structures fill appropriately.
LEFT COMMON CAROTID ARTERY: The catheter was used to select the left common
carotid artery. DSA in the AP and lateral views of the cervical region was
performed. The imaged common, internal, and external carotid arteries are
normal in caliber and contour. The carotid bifurcation is widely patent.
LEFT COMMON CAROTID ARTERY, INTRACRANIAL: The catheter was advanced into
the left internal carotid artery. DSA in the AP, lateral, and oblique views
of the intracranial circulation was performed. The intracranial internal
carotid artery is normal in caliber and contour. The ophthalmic artery is
widely patent. There is a fetal origin to the left posterior cerebral
artery, which appears normal in caliber and contour. The anterior choroidal
artery appears normal. The middle cerebral artery and its distal branches
are normal in caliber and contour. The A1 segment of the anterior cerebral
artery is absent, with no filling of the anterior cerebral artery territory
from this injection. Capillary phase imaging demonstrates normal parenchymal
opacification and arteriovenous transit time. The main intracranial venous
structures fill appropriately.
RIGHT COMMON CAROTID ARTERY: The catheter was used to select the right
common carotid artery. DSA in the AP and lateral views of the cervical
region was performed. The imaged common, internal, and external carotid
arteries are normal in caliber and contour. The carotid bifurcation is
widely patent.
RIGHT INTERNAL CAROTID ARTERY: The catheter was advanced into the right
internal carotid artery. DSA in the AP, lateral, and oblique views of the
intracranial circulation was performed. The intracranial internal carotid
artery is normal in caliber and contour. The ophthalmic artery is widely
patent. There is a prominent posterior communicating artery, with robust
opacification of the right posterior cerebral artery territory. The anterior
choroidal artery appears normal. The middle cerebral artery and its distal
branches are normal in caliber and contour. There is a small saccular
aneurysm arising from a lateral lenticulostriate branch of the right middle
cerebral artery, measuring 2.2 x 2.1 mm. The A1 segment of the right
anterior cerebral artery is prominent in caliber, with filling of both
anterior cerebral artery territories from this injection. There is a
saccular aneurysm arising from the anterior communicating artery, measuring
12.7 x 6.3 x 7.1 mm, with a 7 mm neck, projecting anteriorly and superiorly.
The distal anterior cerebral artery branches are normal in caliber and
branching pattern. Capillary phase imaging demonstrates normal parenchymal
opacification and arteriovenous transit time. The imaged intracranial venous
structures fill appropriately.
RIGHT EXTERNAL ILIAC ARTERY: The sheath was withdrawn into the right
external iliac artery. DSA in the RAO and lateral views of the right
iliofemoral arterial system was performed via injection through the sheath.
The imaged iliofemoral arterial system is widely patent. The angiogram
demonstrated conditions amenable to closure device deployment.
SUPERSELECTIVE ARTERIOGRAPHY, EMBOLIZATION, AND FOLLOWUP ANGIOGRAMS;
SUPERVISION AND INTERPRETATION OF SUPERSELECTIVE ARTERIOGRAPHY,
EMBOLIZATION, AND FOLLOWUP ANGIOGRAMS:
STENT-ASSISTED EMBOLIZATION: The diagnostic catheter was removed and
replaced with a 6 French guiding catheter. The tip of this catheter was
placed into the cervical right internal carotid artery over a guidewire. A
microcatheter was advanced over a microguidewire into the left A2 ACA
segment using roadmap guidance. A second microcatheter was advanced over a
microguidewire into the anterior communicating artery aneurysm sac using
roadmap guidance.
An attempt at primary coil embolization of the aneurysm sac was performed
using a hydro-frame 6 mm x 19 cm coil. A control angiogram (#1) was
performed following placement but prior to deployment of this coil. This
imaging sequence demonstrates filling of the aneurysm sac with coil
material, with significant impingement of the anterior communicating artery
by coil material. Therefore, this coil was removed.
A second attempted primary coil embolization of the aneurysm sac was
performed using a Cosmos Complex 6 mm x 26 cm coil. A control angiogram (#2)
was performed following placement but prior to deployment of this coil. This
imaging sequence demonstrates filling of the aneurysm sac with coil
material, with significant impingement of the anterior communicating artery
by coil material. Therefore, this coil was removed.
Stent-assisted coil embolization was performed. An LVIS Jr. 2.5 x 17 mm
stent was advanced through the first microcatheter into the A2 segment of
the left anterior cerebral artery. The stent was deployed under roadmap
guidance and continuous fluoroscopic surveillance. The microcatheter was
removed, and a control angiogram (#3) was performed following deployment of
the stent. This imaging sequence demonstrates appropriate positioning and
wide patency of the stent, with excellent coverage of the aneurysm neck. No
evidence of thrombus formation or distal embolization.
Coil embolization was then performed. A total of 10 coils were attempted,
and 10 coils were deployed. Control angiograms (#4-11) were performed
intermittently throughout the procedure to evaluate the results of the
embolization. These control angiograms demonstrate appropriate positioning
of the coil material within the aneurysm sac, with no herniation of coil
material into the parent vessel. There is progressive filling of the
aneurysm sac, with progressively decreasing contrast opacification of the
aneurysm lumen.
The microcatheter was removed and a final control angiogram (#12) in the AP
and lateral views was performed from the guiding catheter with filming over
the intracranial circulation. This imaging sequence demonstrates appropriate
positioning of the coil material within the aneurysm sac, with no herniation
of coil material into the parent artery. There is minimal residual filling
at the base of the aneurysm posteriorly, with no filling of the aneurysm
dome. The stent remains widely patent. No thrombus formation or evidence of
distal embolization. Capillary phase imaging demonstrates normal parenchymal
opacification and arteriovenous transit time. The main intracranial venous
structures fill appropriately.
IMPRESSION:
1. Anterior communicating artery aneurysm, measuring 12.7 x 6.3 x 7.1 mm,
with a 7 mm neck, projecting anteriorly and superiorly.
2. The above-described aneurysm was treated with stent-assisted coil
embolization, resulting in minimal residual filling at the aneurysm base
posteriorly and no residual filling of the aneurysm dome.
3. Right middle cerebral artery trunk perforator aneurysm, measuring 2.2 x
2.1 mm.
Doctor reported:
36200
61624
75894
36222x2
36224x1
36228x1
75898x11
75896
I think:
61624
36222x1
36224x1
36228x1
75898 x ?
75896
ICD Codes / Adm.Diagnosis: 437.3 / angio Cerebral aneurysm without rupt
Examination: XA CAROTID/CERV BI W CATH SI -
Accession No:
Reason: aneurysm
REPORT:
CLINICAL INDICATION: Anterior communicating artery aneurysm for evaluation
and potential endovascular treatment.
CONTROL ANGIOGRAMS: 12
COMPLICATIONS: None.
GENERAL ANESTHESIA: Pre-procedure evaluation confirmed that the patient was
an appropriate candidate for general anesthesia. Adequate anesthesia was
maintained during the entire procedure by the anesthesia team. Vital signs
and pulse oximetry were monitored and recorded by the anesthetist throughout
the procedure and the recovery period. The flow sheet was placed in the
medical record including the medications and dosages used. No immediate
anesthesia related complications were noted.
PRE-PROCEDURE: The patient was seen and examined. The chart and images were
reviewed. I had a lengthy discussion with the patient and/or their family
regarding the disease process, as well as potential treatment options, which
include medical management, surgical treatment, or endovascular treatment.
The risks, benefits, and alternatives to the procedure were explained to the
patient and/or the family, and written informed consent was obtained.
PROCEDURE: A Time-Out was performed prior to the procedure to confirm the
patient's identity and the appropriate procedure. The patient was placed
supine on the angiographic table, and the right groin was prepped and draped
in the usual sterile manner. Using a 5 French micropuncture set, the right
common femoral artery was punctured and cannulated, and a 6 French arterial
sheath was placed over a guidewire. The sheath was attached to continuous
heparinized saline flush. A catheter was placed through the sheath and
advanced over a Terumo guidewire into the aortic arch.
Selective catheterization of the following blood vessels was performed (see
below). At the end of the procedure, hemostasis was achieved. Hemostasis was
achieved through closure device placement. Following hemostasis, with no
hematoma, the site was cleaned and dressed with sterile dressing.
Intravenous heparin was intermittently administered throughout the
procedure, monitored with serial ACT measurements, with the ACT maintained
at 250-300. The heparin was not reversed following the procedure.
DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC
ARTERIOGRAMS:
LEFT SUBCLAVIAN ARTERY: The catheter was advanced into the left subclavian
artery. DSA imaging was performed in the AP and lateral projections, with
imaging over the cervical region. The left subclavian artery demonstrates
slight atherosclerotic disease, with no stenosis.. The left vertebral artery
is widely patent at its origin and normal in caliber throughout its cervical
course. The thyrocervical and costocervical trunks are widely patent. The
internal mammary artery is widely patent at its origin.
LEFT VERTEBRAL ARTERY: The catheter was advanced into left vertebral
artery. DSA in the AP and lateral views of the intracranial circulation was
performed. The left vertebral artery is normal in caliber and contour. The
left PICA is normal in caliber and contour. Excellent cross-filling of the
V4 right vertebral artery demonstrates normal caliber and contour of the
right PICA. The basilar artery is normal in caliber and contour. The
bilateral anterior inferior cerebellar and superior cerebellar arteries are
normal caliber and contour. The left posterior cerebral artery is absent.
The P1 segment of the right posterior cerebral artery is hypoplastic, with
flash filling of the right posterior cerebral artery territory from this
injection. No stenosis, occlusion, dissection, aneurysm, or vascular
malformation. Capillary phase imaging demonstrates normal parenchymal
opacification and arteriovenous transit time. The main intracranial venous
structures fill appropriately.
LEFT COMMON CAROTID ARTERY: The catheter was used to select the left common
carotid artery. DSA in the AP and lateral views of the cervical region was
performed. The imaged common, internal, and external carotid arteries are
normal in caliber and contour. The carotid bifurcation is widely patent.
LEFT COMMON CAROTID ARTERY, INTRACRANIAL: The catheter was advanced into
the left internal carotid artery. DSA in the AP, lateral, and oblique views
of the intracranial circulation was performed. The intracranial internal
carotid artery is normal in caliber and contour. The ophthalmic artery is
widely patent. There is a fetal origin to the left posterior cerebral
artery, which appears normal in caliber and contour. The anterior choroidal
artery appears normal. The middle cerebral artery and its distal branches
are normal in caliber and contour. The A1 segment of the anterior cerebral
artery is absent, with no filling of the anterior cerebral artery territory
from this injection. Capillary phase imaging demonstrates normal parenchymal
opacification and arteriovenous transit time. The main intracranial venous
structures fill appropriately.
RIGHT COMMON CAROTID ARTERY: The catheter was used to select the right
common carotid artery. DSA in the AP and lateral views of the cervical
region was performed. The imaged common, internal, and external carotid
arteries are normal in caliber and contour. The carotid bifurcation is
widely patent.
RIGHT INTERNAL CAROTID ARTERY: The catheter was advanced into the right
internal carotid artery. DSA in the AP, lateral, and oblique views of the
intracranial circulation was performed. The intracranial internal carotid
artery is normal in caliber and contour. The ophthalmic artery is widely
patent. There is a prominent posterior communicating artery, with robust
opacification of the right posterior cerebral artery territory. The anterior
choroidal artery appears normal. The middle cerebral artery and its distal
branches are normal in caliber and contour. There is a small saccular
aneurysm arising from a lateral lenticulostriate branch of the right middle
cerebral artery, measuring 2.2 x 2.1 mm. The A1 segment of the right
anterior cerebral artery is prominent in caliber, with filling of both
anterior cerebral artery territories from this injection. There is a
saccular aneurysm arising from the anterior communicating artery, measuring
12.7 x 6.3 x 7.1 mm, with a 7 mm neck, projecting anteriorly and superiorly.
The distal anterior cerebral artery branches are normal in caliber and
branching pattern. Capillary phase imaging demonstrates normal parenchymal
opacification and arteriovenous transit time. The imaged intracranial venous
structures fill appropriately.
RIGHT EXTERNAL ILIAC ARTERY: The sheath was withdrawn into the right
external iliac artery. DSA in the RAO and lateral views of the right
iliofemoral arterial system was performed via injection through the sheath.
The imaged iliofemoral arterial system is widely patent. The angiogram
demonstrated conditions amenable to closure device deployment.
SUPERSELECTIVE ARTERIOGRAPHY, EMBOLIZATION, AND FOLLOWUP ANGIOGRAMS;
SUPERVISION AND INTERPRETATION OF SUPERSELECTIVE ARTERIOGRAPHY,
EMBOLIZATION, AND FOLLOWUP ANGIOGRAMS:
STENT-ASSISTED EMBOLIZATION: The diagnostic catheter was removed and
replaced with a 6 French guiding catheter. The tip of this catheter was
placed into the cervical right internal carotid artery over a guidewire. A
microcatheter was advanced over a microguidewire into the left A2 ACA
segment using roadmap guidance. A second microcatheter was advanced over a
microguidewire into the anterior communicating artery aneurysm sac using
roadmap guidance.
An attempt at primary coil embolization of the aneurysm sac was performed
using a hydro-frame 6 mm x 19 cm coil. A control angiogram (#1) was
performed following placement but prior to deployment of this coil. This
imaging sequence demonstrates filling of the aneurysm sac with coil
material, with significant impingement of the anterior communicating artery
by coil material. Therefore, this coil was removed.
A second attempted primary coil embolization of the aneurysm sac was
performed using a Cosmos Complex 6 mm x 26 cm coil. A control angiogram (#2)
was performed following placement but prior to deployment of this coil. This
imaging sequence demonstrates filling of the aneurysm sac with coil
material, with significant impingement of the anterior communicating artery
by coil material. Therefore, this coil was removed.
Stent-assisted coil embolization was performed. An LVIS Jr. 2.5 x 17 mm
stent was advanced through the first microcatheter into the A2 segment of
the left anterior cerebral artery. The stent was deployed under roadmap
guidance and continuous fluoroscopic surveillance. The microcatheter was
removed, and a control angiogram (#3) was performed following deployment of
the stent. This imaging sequence demonstrates appropriate positioning and
wide patency of the stent, with excellent coverage of the aneurysm neck. No
evidence of thrombus formation or distal embolization.
Coil embolization was then performed. A total of 10 coils were attempted,
and 10 coils were deployed. Control angiograms (#4-11) were performed
intermittently throughout the procedure to evaluate the results of the
embolization. These control angiograms demonstrate appropriate positioning
of the coil material within the aneurysm sac, with no herniation of coil
material into the parent vessel. There is progressive filling of the
aneurysm sac, with progressively decreasing contrast opacification of the
aneurysm lumen.
The microcatheter was removed and a final control angiogram (#12) in the AP
and lateral views was performed from the guiding catheter with filming over
the intracranial circulation. This imaging sequence demonstrates appropriate
positioning of the coil material within the aneurysm sac, with no herniation
of coil material into the parent artery. There is minimal residual filling
at the base of the aneurysm posteriorly, with no filling of the aneurysm
dome. The stent remains widely patent. No thrombus formation or evidence of
distal embolization. Capillary phase imaging demonstrates normal parenchymal
opacification and arteriovenous transit time. The main intracranial venous
structures fill appropriately.
IMPRESSION:
1. Anterior communicating artery aneurysm, measuring 12.7 x 6.3 x 7.1 mm,
with a 7 mm neck, projecting anteriorly and superiorly.
2. The above-described aneurysm was treated with stent-assisted coil
embolization, resulting in minimal residual filling at the aneurysm base
posteriorly and no residual filling of the aneurysm dome.
3. Right middle cerebral artery trunk perforator aneurysm, measuring 2.2 x
2.1 mm.