J Cerebrovasc Endovasc Neurosurg.  2021 Jun;23(2):123-129. 10.7461/jcen.2021.E2020.09.002.

Salvage flow diverter stent across the posterior communicating artery for persistent retrograde filling of a giant internal carotid artery aneurysm after parent vessel occlusion

• Manzoor MU
• AlRashed AA
• Alghabban FA
• Alqahtani SM
• Alturki AY

• KMID: 2517025
• DOI: http://doi.org/10.7461/jcen.2021.E2020.09.002

Abstract

Giant internal carotid artery (ICA) aneurysms are complex vascular lesions which are difficult to treat with open as well as endovascular surgery. Parent vessel occlusion is a well-established treatment option for such aneurysms. However, there have been a few reported cases of ruptured aneurysms related to the persistent retrograde filling after parent vessel occlusion. We report a case which highlights the usage of the flow diverter stent as a potential treatment strategy for the management of retrograde filling of aneurysms. A 54-year-old female was found to have a giant left ICA aneurysm on a brain magnetic resonance imaging during workup for headaches. She underwent occlusion of the left ICA proximal to the aneurysm using multiple coils. However, follow up angiograms after 6 months and 2 years demonstrated persistent retrograde filling of the left ICA aneurysm through the posterior communicating (PCOM) artery. Eventually, she was successfully treated with a flow diverter stent across the PCOM artery into the distal ICA. Follow up angiogram after 6 months showed patent flow in the PCOM artery and the distal ICA. with complete occlusion of the aneurysm. Using a flow diverter stent after insufficient parent vessel occlusion for giant intracranial aneurysms may be a feasible treatment option and an addition to the neurovascular treatment armamentarium.

Keyword

Flow diversion; Giant intracranial aneurysms; Internal carotid artery; Parent vessel sacrifice; Stent

Figure

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  Fig. 1. MRI scan with contrast demonstrating a giant aneurysm arising from the para-ophthalmic segment of the left ICA. MRI, magnetic resonance imaging; ICA, internal carotid artery.

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  Fig. 2. Initial angiogram (A) AP and (B) Lateral views show large left ICA paraphthalmic aneurysm. AP, anteroposterior; ICA, internal carotid artery.

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  Fig. 3. (A) Balloon occlusion test left ICA with balloon inflated in left ICA and angiogram from the right ICA showing brisk filling of the left anterior and middle cerebral artery through a patent anterior communicating artery. (B) Native AP image demonstrating multiple coils used for occlusion of distal left ICA. ICA, internal carotid artery.

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  Fig. 4. (A) Left ICA AP angiogram demonstrating multiple coils causing occlusion of the distal left ICA with no antegrade filling of the left ICA aneurysm. (B) Right ICA AP angiogram post occlusion of the left ICA shows brisk filling of the left anterior and middle cerebral artery through a patent anterior communicating artery. (C, D) Left vertebral artery AP and Lateral views angiogram shows retrograde filling of the left ICA para-ophthalmic aneurysm after occlusion of left ICA. ICA, internal carotid artery; AP, anteroposterior.

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  Fig. 5. (A) Oblique left vertebral angiogram demonstrates filling of the left ICA aneurysm through a patent left PCOM artery. (B) Oblique native image demonstrating the flow diverter stent across the PCOM artery into the distal left ICA terminating below the carotid terminus. ICA, internal carotid artery; PCOM, posterior communicating.

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  Fig. 6. Six months follow up AP and lateral angiogram of the left vertebral artery demonstrating patent PCOM artery aneurysm with no residual filling of the left ICA aneurysm. AP, anteroposterior. PCOM, posterior communicating; ICA, internal carotid artery.

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  Fig. 7. An illustration showing parent ICA occlusion with placement of flow diverter stent across the left PCOM artery into the distal left ICA. ICA, internal carotid artery; PCOM, posterior communicating.

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