J Cerebrovasc Endovasc Neurosurg.  2024 Mar;26(1):65-70. 10.7461/jcen.2023.E2023.04.009.

Treatment of a posterior cerebral artery aneurysm in the context of complex cardio-cerebrovascular variations using the Tubridge flow diverter

• Dmytriw AA
• Grewal S
• Cancelliere NM
• Patel AB
• Pereira VM
• Ren X

• KMID: 2554048
• DOI: http://doi.org/10.7461/jcen.2023.E2023.04.009

Abstract

We present a case of intracranial aneurysm located in the P1 segment of left posterior cerebral artery in the context of tetralogy of Fallot. Complex variations included right aortic arch with abnormal branching. Also, the bilateral vertebral arteries were absent, with a type I persistent proatlantal intersegmental artery of the left side. The aneurysm was treated with endovascular intervention with a Tubridge flow diverter and was noted to be completely cured on 6-month follow-up. We discuss the many considerations in this patient including developmental and modern-era treatment.

Keyword

Interventional neuroradiology; Endovascular aneurysm repair; Flow diversion; Tetralogy of Fallot; Proatlantal artery

Figure

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  Fig. 1. (A, B) Echocardiography illustrating TOF with pulmonic stenosis. (C, D) MRI T2 weighted imaging depicting left PCA aneurysm (arrow) and remote infarctions in the right frontal and parietal lobes (arrows). TOF, tetralogy of Fallot; MRI, magnetic resonance imaging; PCA, posterior cerebral artery

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  Fig. 2. (A, B) Aortic arch angiography (arrow): RAA; the right CCA, left ICA, left ECA and left SA all branched from a common main trunk from the aortic arch. (C, D) SA angiography: bilateral VAs absent. (E, F) Right ICA angiography: patent anterior communicating artery (arrow), right embryonic posterior cerebral artery, and left PCA aneurysm (arrow). (G, H) Left ICA angiography: PIA (arrow). (I, J) left ICA angiography: P1 segment aneurysm (arrow). RAA, right aortic arch; CCA, common carotid artery; ICA, internal carotid artery; ECA, external carotid artery; SA, subclavian artery; VA, vertebral artery; PCA, posterior cerebral artery; PIA, proatlantal intersegmental artery

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  Fig. 3. (A, B) Intraoperative angiography: a saccular wide-necked aneurysm (arrow) in the P1 segment of the left PCA (diameter: body 5.2×3.7 mm, neck 3.1 mm, parent artery 2.3 mm); Tubridge (arrow) FD (2.5/20 mm) semi-release and covering the neck of the aneurysm. (C, D) Immediate angiography after Tubridge FD implantation: decreased contrast filling into the aneurysm sac (arrow). PCA, posterior cerebral artery; FD, flow diverter

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  Fig. 4. (A-C) Left ICA angiography at 6-month follow-up: left P1 aneurysm not visible (arrow) and cured clinically. ICA, internal carotid artery

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