Yonsei Med J.  2017 May;58(3):668-671. 10.3349/ymj.2017.58.3.668.

Quantitative Computed Tomographic Volumetry after Treatment of a Giant Intracranial Aneurysm with a Pipeline Embolization Device

• Lee WJ
• Byun JS
• Kim JK
• Nam TK

• KMID: 2419130
• DOI: http://doi.org/10.3349/ymj.2017.58.3.668

Abstract

Recently developed flow diverters, such as the pipeline embolization device (PED), allow for safe and efficacious treatment of giant intracranial aneurysms, with high occlusion rates and a low incidence of complications. However, incomplete obliteration after PED treatment may lead to aneurysm regrowth and delayed rupture. Herein, we report a case of a partially thrombosed giant aneurysm of the cavernous internal carotid artery that showed progressive recanalization at 1-3 months after application of a PED. We monitored inflow volume in the aneurysm by computed tomographic angiography (CTA) and computed tomographic volumetric imaging (CTVI). Based on the imaging results, rather than applying additional PED, we decided to make the switch from a dual antiplatelet medication to low-dose aspirin alone at 3 months after the treatment; complete obliteration of the aneurysm was noted at 21 months. Similar to the findings in this unusual case, CTA and CTVI may be useful follow-up methods for optimal management of patients with giant intracranial aneurysms after PED treatment.

Keyword

Intracranial aneurysm; therapeutic embolization; medical device; computed tomography; angiography

MeSH Terms

Adult
Aged
Anticoagulants/therapeutic use
Aspirin/therapeutic use
Carotid Artery, Internal/diagnostic imaging
Embolization, Therapeutic/adverse effects/*instrumentation/*methods
Female
Humans
Intracranial Aneurysm/diagnostic imaging/*therapy
Male
Middle Aged
Platelet Aggregation Inhibitors/therapeutic use
Stents
Thrombosis/*diagnostic imaging/drug therapy/etiology
Tomography, X-Ray Computed/*methods
Treatment Outcome
Anticoagulants
Platelet Aggregation Inhibitors
Aspirin

Figure

• 

  Fig. 1 Images of the partially thrombosed aneurysm pre- and post-stenting. (A) Initial T2-weighted magnetic resonance imaging shows a partially thrombosed (asterisk) giant aneurysm in the cavernous segment of the right internal carotid artery. (B and C) Preoperative digital subtraction angiography reveals a giant aneurysm with the inflow jet axis oriented posterosuperiorly toward the aneurysm dome on the sagittal plane. (D and E) Post-treatment completion angiography shows significantly decreased inflow to the aneurysm sac with redirection of the initial inflow jet axis toward the posteroinferior aspect on the sagittal plane. (F) DynaCT identifies the optimal stent position across the aneurysm neck.

• 

  Fig. 2 Serial computed tomographic angiography and computed tomographic volumetric images of a giant aneurysm treated by applying a single pipeline embolization device. The results show a decrease in the inflow volume 1 week after treatment (756.6 mm3, 19.5% of the initial volume) followed by an increase at 1 (1385.4 mm3, 35.7%) and 3 (1565.7 mm3, 40.3%) months. After replacing the antiplatelet with low-dose aspirin alone, the inflow volume decreased to 954.7 mm3 (24.6%) at 4 months, and only a small remnant (124.5 mm3, 3.2%) was detected at 15 months. Inflow into the aneurysm disappeared completely at 21 months. Note the posteroinferior redirection of the aneurysm axis during obliteration on the sagittal images. CTVI, computed tomographic volumetric image.

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