Background: Neurosurgeons rarely encounter intracranial aneurysms involving the right aortic arch (RAA). We, herein, report a case of ruptured cerebral aneurysm with RAA treated with neuroendovascular therapy through direct carotid puncture (DCP) without complications. Case Description: A 77-year-old woman was rushed to our hospital with sudden loss of consciousness. Computed tomography scan of the head showed Fisher group 3 subarachnoid hemorrhage. Three-dimensional computed tomography angiography showed a left internal carotid artery-posterior communicating artery aneurysm, and coil embolization was attempted. Intraoperative cerebral angiography revealed that RAA and the left common carotid artery (CCA) originated at an extremely acute angle from the cardiac base. Catheter guidance from both the femoral artery and brachial artery (BRA) were unsuccessful; therefore, coil embolization was performed through DCP. Using a 6Fr short sheath was placed in the CCA, and the surgery was completed using the balloon-assisted technique. The problem was uneventful with the stability of the balloon catheter or microcatheter during surgery. After surgery, the patient was transferred to a convalescent rehabilitation hospital with modified Rankin scale score of 3. Conclusion: When performing neuroendovascular therapy in patients with RAA, it is necessary to pay attention to the bifurcation position and angle of the target branching vessels and to consider the options for approaching, including DCP.
Ichihashi et al. (Fri,) studied this question.