Detailed Treatment Process
Female, 54 years old This was a follow-up visit one and a half years after interventional treatment for a paraclinoid segment aneurysm of the left internal carotid artery. The purpose of this admission was to fulfill the follow-up recommendation given in the discharge summary from the previous hospitalization, which advised a review after one year.
Neurosurgery Operative Record Department: Neurosurgery Preoperative diagnosis: Recurrence of paraclinoid segment aneurysm of the left internal carotid artery after interventional treatment Postoperative diagnosis: Recurrence of paraclinoid segment aneurysm of the left internal carotid artery after interventional treatment Procedure and indications: Coil embolization of paraclinoid segment aneurysm of the left internal carotid artery Intraoperative findings: Initial angiography showed aneurysmal dilation at the base of the original paraclinoid segment aneurysm of the left internal carotid artery, with contrast filling inside. Most of the original aneurysm sac was densely packed with coils, and a stent was visible in the parent artery. A microcatheter was advanced through the stent struts with the assistance of a microwire and positioned inside the aneurysm. A total of 12 coils were deployed. Follow-up angiography confirmed near-complete occlusion of the aneurysm, with no obvious abnormalities in the distal vessels. Procedure details: Under general anesthesia, intubation was smooth. 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 showed aneurysmal dilation at the base of the original paraclinoid segment aneurysm of the left internal carotid artery, with contrast filling inside. Most of the original aneurysm sac was densely packed with coils, and a stent was visible in the parent artery. After systemic heparinization, a microcatheter was advanced through the stent struts with the assistance of a microwire and positioned inside the aneurysm. The following coils were deployed: 6mm×15mm (1), 5mm×15mm (1), 5mm×10mm (2), 4mm×10mm (2), 4mm×10mm (2), 4mm×6mm (2), 3mm×8mm (1), 3mm×6mm (1). Follow-up angiography confirmed near-complete occlusion of the aneurysm, with no obvious abnormalities in the distal vessels. The procedure was then concluded. After anesthesia recovery, the tube was removed. The patient was alert, responded appropriately to questions, with bilateral pupils measuring 2.5 mm and brisk light reflexes. Limb movements were normal. She was returned to the ward in stable condition. Brief medical history and physical examination: 1. Female patient, 54 years old. 2. Admitted for “one and a half years after interventional treatment for a paraclinoid segment aneurysm of the left internal carotid artery.” 3. Physical findings: T: 36.8℃, P: 84 beats/min, R: 21 breaths/min, BP: 116/78 mmHg. The patient was alert, with a natural expression, normal orientation, and GCS 15. Both pupils measured 2.5 mm, were equal and round, with brisk light reflexes. Neurological examination was unremarkable. No pathological reflexes were elicited. Bilateral Babinski signs were negative. Limb movements were normal, with muscle strength V in both upper limbs and V in both lower limbs, and normal muscle tone.
Following the interventional procedure, the patient developed a stroke. She filed a complaint with the hospital, which provided the following response: Opinions on the Patient’s Diagnosis and Treatment I. Basic patient information: Name: (omitted) Gender: Female Age: 54 years Date of admission: June 14 Admission diagnosis: Status post interventional treatment for paraclinoid segment aneurysm of the left internal carotid artery Current diagnosis: Status post interventional treatment for paraclinoid segment aneurysm of the left internal carotid artery; recurrent aneurysm; status post coil embolization of aneurysm; cerebral infarction II. Course of events: The patient was admitted on June 13, 2011, for a follow-up visit one and a half years after interventional treatment for a paraclinoid segment aneurysm of the left internal carotid artery. On June 14, cerebral angiography (DSA) was performed. Intraoperative imaging revealed aneurysmal dilation at the base of the original left paraclinoid aneurysm with contrast filling inside, confirming recurrence. After the neurosurgeon provided full disclosure to the family, they agreed to proceed with another interventional procedure. The surgical risks were explained preoperatively, and the family consented and signed the form. Coil embolization was performed on June 16. Postoperative DSA showed non-visualization 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 muscle strength in the right limbs. Antiepileptic treatment was initiated immediately. 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 an infarct in the left frontoparietal region. Once the condition stabilized, the family was advised to transfer her to a rehabilitation hospital as soon as possible for hyperbaric oxygen therapy and limb and speech exercises to promote functional recovery. The family refused and insisted on continued treatment in the neurosurgery ward. Despite repeated recommendations from the medical team, they did not respond. At present, the patient is alert, with partial sensory aphasia, able to produce isolated syllables. Muscle strength is grade I in the right upper limb and grade IV in the right lower limb. She is able to walk independently with the aid of a cane. III. Hospital’s position: The diagnosis of recurrent paraclinoid segment aneurysm of the left internal carotid artery was clear and met the indications for interventional treatment. Cerebral infarction occurred postoperatively; this risk had been disclosed to the family before surgery. After the infarction, the neurosurgery team promptly confirmed the diagnosis and provided appropriate treatment. The patient’s condition stabilized, and neurological function showed partial recovery. The hospital again recommends regular medication and early transfer to a rehabilitation facility for further therapy. In summary, the hospital’s diagnostic and treatment actions complied with standard medical practice. We hope the family can understand this. If they have any objections, they may apply for medical malpractice assessment through the relevant authorities or file a lawsuit in court. December 14
The patient was never transferred out of the neurosurgery ward, which prevented final billing. Below is a partial itemized list of expenses from the first interventional 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 \ piece \ 5,660.000 \ 3 \ 16980.00 Guidewire/SILVERSPEED 10 or 14 \ piece \ 2,570.000 \ 1 \ 2570.00 Guidewire/X-CELERATOR 10 or 14 \ piece \ 2,570.000 \ 1 \ 2570.00 Electrolytic detachable coil/NEXUS \ each \ 11,500.000 \ 4 \ 46000.00 The cerebral infarction that occurred after this interventional procedure is detailed in the hospital’s response document above. The hospitalization expense list from one and a half years earlier showed that self-pay costs for surgical materials used in the embolization procedure totaled $200,000, including coils, vascular embolization systems, vascular reconstruction devices and delivery systems, microcatheters, and other materials. The type and cost of this procedure were similar to the embolization performed one and a half years earlier. One and a half years ago, the patient also underwent aneurysm embolization. At that time, she was asymptomatic. She had been treated for migraine at another hospital, where her headache symptoms resolved. She then came to this hospital simply to investigate the cause of her migraines. Upon arrival, she underwent the first coil embolization. The discharge summary from the first procedure recommended a follow-up review after one year. This visit was for that scheduled follow-up. Unexpectedly, another aneurysm was discovered, leading to a second embolization. The key difference is that this time, the patient suffered a stroke afterward, resulting in hemiplegia and aphasia as permanent sequelae.