Detailed Treatment Process
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Female, 54 years old This was a follow-up visit one and a half years after endovascular treatment of a left paraclinoid internal carotid artery aneurysm. The purpose of this admission was to comply with the discharge instructions from the previous hospitalization, which recommended a one-year follow-up review.
Neurosurgical Operative Record Department: Neurosurgery Preoperative diagnosis: Recurrence of left paraclinoid internal carotid artery aneurysm after endovascular treatment Postoperative diagnosis: Recurrence of left paraclinoid internal carotid artery aneurysm after endovascular treatment Procedure: Endovascular coil embolization of left paraclinoid internal carotid artery aneurysm Intraoperative findings: Angiography showed aneurysmal dilation at the base of the previously treated left paraclinoid internal carotid artery aneurysm with contrast filling. Most of the original aneurysm sac was densely packed with coils, and a stent was visible within the parent artery. A microcatheter was advanced through the stent struts with microwire assistance and positioned inside the aneurysm. Twelve coils were deployed. Follow-up angiography confirmed near-complete occlusion of the aneurysm with no significant abnormalities in the distal vessels. Procedure details: Under general anesthesia, endotracheal intubation was performed without difficulty. The patient was placed in the supine position. The right femoral artery was punctured successfully, and a 6F arterial sheath was inserted. A 6F guiding catheter was advanced into the left internal carotid artery under fluoroscopy and secured. Initial angiography revealed aneurysmal dilation at the base of the original left paraclinoid aneurysm with contrast filling. Most of the aneurysm sac was densely packed with coils, and a stent was visible in the parent artery. After systemic heparinization, a microcatheter was navigated through the stent struts with microwire assistance and positioned within the aneurysm. The following coils were deployed: one 6 mm × 15 mm, one 5 mm × 15 mm, two 5 mm × 10 mm, two 4 mm × 10 mm, two 4 mm × 10 mm, two 4 mm × 6 mm, one 3 mm × 8 mm, and one 3 mm × 6 mm. Follow-up angiography showed near-complete aneurysm occlusion with patent distal vessels. The procedure was then concluded. After emergence from anesthesia, the endotracheal tube was removed. The patient was alert and oriented, with equal pupils measuring 2.5 mm that reacted briskly to light, and full limb movement. She was returned to the ward in stable condition. Brief history and physical examination: 1. Female patient, 54 years old. 2. Admitted for follow-up one and a half years after endovascular treatment of a left paraclinoid internal carotid artery aneurysm. 3. Vital signs: Temperature 36.8°C, pulse 84 beats/min, respirations 21 breaths/min, blood pressure 116/78 mmHg. The patient was alert and oriented with a GCS score of 15. Both pupils were 2.5 mm, round, and equal, with brisk light reflexes. Neurological examination was unremarkable. No pathological reflexes were elicited. Bilateral Babinski signs were negative. Limb strength was grade V in all extremities with normal muscle tone.
Following the interventional procedure, the patient developed a stroke. She filed a complaint with the hospital, which responded as follows: Opinion on the Patient’s Diagnosis and Treatment I. Basic patient information: Name: (omitted) Gender: Female Age: 54 years Admission date: June 14 Admission diagnosis: Status post endovascular treatment of left paraclinoid internal carotid artery aneurysm Current diagnosis: Status post endovascular treatment of left paraclinoid internal carotid artery aneurysm; recurrent aneurysm; status post coil embolization; cerebral infarction II. Course of events: The patient was admitted on June 13 for follow-up one and a half years after endovascular treatment of a left paraclinoid internal carotid artery aneurysm. On June 14, cerebral angiography (DSA) was performed. It revealed aneurysmal dilation at the base of the original aneurysm with contrast filling, confirming recurrence. After the neurosurgeon provided full disclosure to the family, they agreed to proceed with repeat endovascular treatment. The surgical risks were explained, and the family signed the consent form. Coil embolization was performed on June 16. Post-procedure DSA showed non-filling of the aneurysm with patency of the left internal carotid artery and its distal branches. Approximately two hours after the procedure, the patient experienced a seizure. On examination she was drowsy, opened her eyes to voice, withdrew to painful stimuli, was unable to speak, and had decreased strength in the right limbs. Antiepileptic treatment was started. Head CT showed no hemorrhage. Acute cerebral infarction was suspected, and she was transferred to the NICU. A repeat head CT the next morning confirmed a left frontoparietal infarct. Once her condition stabilized, the family was advised to transfer her promptly to a rehabilitation hospital for hyperbaric oxygen therapy and physical and speech rehabilitation to promote functional recovery. The family declined and insisted on continued treatment in the neurosurgery ward. Multiple recommendations from the medical team were not accepted. The patient is currently alert with partial sensory aphasia (as stated in the original), able to produce single syllables, right upper limb strength grade I, right lower limb strength grade IV, and can walk independently with a cane. III. Hospital position: The diagnosis of recurrent left paraclinoid internal carotid artery aneurysm was clear and met the indications for endovascular treatment. Cerebral infarction is a known risk that was disclosed to the family before surgery. After the infarction occurred, the neurosurgery team promptly diagnosed and treated the complication. The patient’s condition stabilized and she showed partial neurological recovery. We again recommend regular medication and early transfer to a rehabilitation facility. In summary, our hospital’s diagnosis and treatment complied with standard medical practice. We hope the family can understand this. If they disagree, they may apply for medical damage assessment through the relevant authorities or file a lawsuit in court. December 14
The patient remained in the neurosurgery ward, which prevented final billing. The following is a partial list of expenses from the first coil embolization procedure: Item \ Unit \ Unit price \ Quantity \ Amount Perfusion catheter \ piece \ 6,300.000 \ 1 \ 6300.00 Microplex coil system \ each \ 8,673.000 \ 8 \ 69384.00 Hydrocoil embolization system \ each \ 15,200.000 \ 1 \ 15200.00 Vascular reconstruction device and delivery system \ each \ 26,198.550 \ 1 \ 26198.55 Microcatheter \ each \ 5,660.000 \ 3 \ 16980.00 Guidewire/SILVERSPEED 10 or 14 \ each \ 2,570.000 \ 1 \ 2570.00 Guidewire/X-CELERATOR 10 or 14 \ each \ 2,570.000 \ 1 \ 2570.00 Electrolytic detachable coil/NEXUS \ each \ 11,500.000 \ 4 \ 46000.00
The patient developed cerebral infarction after this procedure; details are provided in the hospital’s response above. The hospitalization cost list from one and a half years earlier shows that the out-of-pocket amount for surgical materials used in the embolization totaled $200,000, including coils, embolization systems, vascular reconstruction devices and delivery systems, microcatheters, and similar items. The current procedure and associated costs were similar to those of the first intervention one and a half years earlier. The first embolization was also performed on an asymptomatic aneurysm. At that time the patient had been treated for migraine at another hospital, where her headaches resolved. She came to this hospital simply to investigate the cause of the migraines. The first coil embolization was performed during that visit. The discharge summary from the first procedure recommended follow-up after one year. The current admission was for that routine follow-up. Unexpectedly, a recurrent aneurysm was found and another embolization was performed. The key difference is that this second procedure was followed by a stroke, resulting in hemiplegia and aphasia.