J Cerebrovasc Endovasc Neurosurg.  2016 Mar;18(1):19-26. 10.7461/jcen.2016.18.1.19.

Delayed Ischemic Stroke after Flow Diversion of Large Posterior Communicating Artery Aneurysm

• Kim SO
• Chung YG
• Won YS
• Rho MH

• KMID: 2161698
• DOI: http://doi.org/10.7461/jcen.2016.18.1.19

Abstract

For securing large, giant, and wide-neck aneurysms, conventional coil embolization has substantial limitations, such as incomplete occlusion, recanalization, and a high recurrence rate. To overcome these limitations, a novel paradigm was suggested and, as a result, flow-diverting device was developed. The flow-diverting device is an innovative and effective technique to allow securing of large, giant, and wide-neck aneurysms. In numerous studies, the flow-diverting device has shown better outcomes than coil embolization. However, the flow-diverting device has also some risks, including rupture of aneurysm, intracerebral hemorrhage, and ischemic stroke. In addition, with more experience, unexpected complications are also reported.5) 7) In the present case, we experienced a delayed ischemic stroke at 27 days after endovascular treatment. The patient had multiple aneurysms and, among them, we treated a large posterior communicating artery aneurysm using Pipelineâ„¢ Embolization Device. The patient was tolerable for 25 days, but then suddenly presented intermittent right hemiparesis. In the initial diffusion magnetic resonance imaging (MRI), there was no acute lesion; however, in the follow-up MRI, an acute ischemic stroke was found in the territory of anterior choroidal artery which was covered by Pipeline Embolization Device. We suspect that neo-intimal overgrowth or a tiny thrombus have led to this delayed complication. Through our case, we learned that the neurosurgeon should be aware of the possibility of delayed ischemic stroke after flow diversion, as well as, long-term close observation and follow-up angiography are necessary even in the event of no acute complications.

Keyword

Flow diversion; Pipeline embolization device; Anterior choroidal artery occlusion; Ischemic stroke; Complication

MeSH Terms

Aneurysm
Angiography
Arteries
Cerebral Hemorrhage
Choroid
Diffusion Magnetic Resonance Imaging
Embolization, Therapeutic
Follow-Up Studies
Humans
Intracranial Aneurysm*
Magnetic Resonance Imaging
Paresis
Recurrence
Rupture
Stroke*
Thrombosis

Figure

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  Fig. 1 3D reconstruction of the left ICA angiography. A large PCoA aneurysm is located between PCoA and AChA (neck: 11 mm, length: 18 mm, width: 9 mm, postero-inferior projection). Proximal PCoA originates from the aneurysm neck, but proximal AChA is slightly separated from the aneurysm. ACoA and left MCA aneurysms are also visible (Black star: Large PCoA aneurysm, White arrow: AChA, Arrow head: PCoA). Lt = left; ICA = internal carotid artery; PCoA = posterior communicating artery; AChA = anterior choroidal artery; ACoA = anterior communicating artery; MCA = middle cerebral artery.

• 

  Fig. 2 (A, B) Post-operative right anterior oblique and lateral view. (C, D) 3D reconstruction of PED and coils. (C, D) PED is well-attached to the distal ICA wall (Black star: Large PCoA aneurysm, Arrow head: Deployed PED, White arrow: coil embolization of the left ACoA, MCA aneurysms, Black arrow: cranial fixator of a previous craniotomy, Black star: Large PCoA aneurysm). PED = Pipeline™ Embolization Device; ICA = internal carotid artery; PCoA = posterior communicating artery; ACoA = anterior communicating artery; MCA = middle cerebral artery.

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  Fig. 3 (A) Post-operative angiographyin the arterial phase. After the deployment of PED, all of the branch vessels, including AChA and PCoA, are well-maintained. (B) Post-operative angiography in the venous phase. The flow stagnation at PCoA aneurysm sac is observed (White arrow: AChA, Arrow head: PCoA). PED = Pipeline™ Embolization Device; AChA = anterior choroidal artery; PCoA = posterior communicating artery.

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  Fig. 4 Diffusion MRI scan at 25 days after the endovascular treatment. The patient presented intermittent right hemiparesis, but there was no acute lesion in the territory of left AChA. MRI = magnetic resonance imaging; AChA = anterior choroidal artery.

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  Fig. 5 Diffusion MRI scan at 27 days after the endovascular treatment. The patient's hemiparesis was aggravated, so we rechecked diffusion MRI again. In follow-up MRI, acute ischemic stroke was found in the territory of the left AChA. MRI = magnetic resonance imaging; AChA = anterior choroidal artery.

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