Neurointervention.  2022 Jul;17(2):126-130. 10.5469/neuroint.2022.00045.

The Use of a Pipeline Embolization Device for Treatment of a Ruptured Dissecting Middle Cerebral Artery M3/M4 Aneurysm: Challenges and Technical Considerations

• Berwanger RP
• Hoover MC
• Scott JA
• DeNardo AJ
• Amuluru K
• Payner TD
• Kulwin CG
• Sahlein DH

• KMID: 2531570
• DOI: http://doi.org/10.5469/neuroint.2022.00045

Abstract

Prompt, effective treatment is necessary following aneurysmal subarachnoid hemorrhage to prevent recurrent rupture, which is thought to double mortality. Atypical ruptured aneurysms, such as blister or dissecting pseudoaneurysms, or those that are unusually distal in the middle cerebral artery (MCA) are challenging to treat with either open or endovascular options, though the pipeline embolization device (PED) has shown promise in multiple case series. We present a case of a ruptured dissecting pseudoaneurysm in the distal MCA (distal M3/proximal M4) prefrontal division in an healthy young patient (<60 years) successfully treated with a PED. The PED was chosen both as the only vessel sparing option in the young patient as well as for its potential as a vessel sacrifice tool if the pseudoaneurysm was felt to be incompletely treated, which in this case was not necessary—though would have leveraged the thrombogenicity of the device as a therapeutic advantage.

Keyword

Pseudoaneurysm; Subarachnoid hemorrhage; Embolization, therapeutic; Middle cerebral artery

Figure

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  Fig. 1. (A) Noncontrast head axial CT demonstrates parenchymal (large black arrow), subarachnoid (small black arrow), and subdural (grey arrow) hemorrhage in the left hemisphere prefrontal mid convexity. There is surrounding edema (white arrow). (B) Catheter angiography of left internal carotid in the capillary phase shows the dissecting segment (white arrow) coursing through the center of a region of oligemia (black arrows) confirming that this ruptured M3/M4 pseudoaneurysm is the cause of hemorrhage. (C) 3D angiography demonstrates the ruptured M3/M4 dissecting aneurysm. (D) Magnified postprocedural angiography demonstrates appropriate positioning of the stent (white arrows) across the diseased and dissecting segment. (E) Six-month follow-up 3D angiography demonstrates patency of the stent (white arrows) and normal antegrade flow into the dominant (grey arrow) and jailed (black arrow) divisions of the prefrontal segment of the left middle cerebral artery. The stent (white arrows) has expanded to the nominal diameter of 2.5 mm during the 6-month interval follow-up. (F) Six-month follow-up MRI shows encephalomalacia/gliosis in the area of prior parenchymal hemorrhage (black arrows) with no additional signal abnormality either superior to the dominant collection or posterior to the collection (white arrow). CT, computed tomography; MRI, magnetic resonance imaging.

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