PMC9479598_01
Radiological imaging of a 74-year-old woman who presented with the right intracranial giant internal carotid artery aneurysm. (a) Head magnetic resonance (MR) imaging shows a 32 mm round mass with a flow void compressing right hypothalamus (arrow). (b) Lateral view of the right internal carotid angiogram shows a giant aneurysm at the supraclinoid portion of the internal carotid artery (arrow). (c) A posterior-lateral-inferior view of reconstructed three-dimensional right internal carotid angiogram shows orifices of the posterior communicating artery and anterior choroidal artery across the wide aneurysmal neck. (d) Intraoperative working angle fluoroscopy shows deployed flow diverter (arrowheads) with intra-aneurysmal detachable coils (arrow) being packed. (e) Postprocedural common carotid angiogram shows remarkable flow reduction of the aneurysm with a small amount of neck remnant (arrow). (f) Head MR imaging 10 months after the flow diverter placement shows aneurysm enlargement to 38 mm (arrow) with perifocal edema (arrowheads). (g) Head MR imaging at the level of the anterior horn of the lateral ventricle shows hydrocephalus caused by obstruction of bilateral foramen of Monro (arrow). (h) The right internal carotid angiogram at aneurysmal enlargement shows residual intra-aneurysmal flow (arrow) with deformed coils.
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A 74-year-old woman presented with intermittent headache and screening magnetic resonance imaging (MRI) showed a suprasellar mass lesion with a flow void, which was confirmed with cerebral angiography as a 32 mm giant aneurysm at the supraclinoid segment of the right ICA [Figures 1a and b]. The AchA and the posterior communicating artery (PCoA) arose from the same segment as the aneurysm across the ICA [Figure 1c]. The patient was treated with FD placement, where Pipeline Flex (4.75 mm x 25 mm, Medtronic, Minneapolis, USA) was placed from the M1 portion of the middle cerebral artery to the ophthalmic segment of the ICA with rough aneurysmal packing with detachable coils, which significantly reduced intra-aneurysmal blood flow [Figures 1d and e]. Repeat MRI showed aneurysmal enlargement to 38 mm with remarkable perianeurysmal edema, together with hydrocephalus caused by obstruction of bilateral foramen of Monro [Figures 1f and g]. Cerebral angiography showed residual blood flow at the aneurysmal neck with coil mass deformation [Figure 1h].
Schematic imaging, operative findings, and postoperative course, of the flow alteration treatment in the hybrid operating room. (a) Schematic imaging of the treatment strategy. A high-flow external carotid artery-radial artery graft-middle cerebral artery bypass is made, and the internal carotid artery is obliterated with coils just proximal to the posterior communicating artery. Black arrows show direction of the blood flow after the procedure. (b) Intraoperative photograph of the extracranial-intracranial bypass, cranial part. The free radial artery graft (arrow) and superficial temporal artery (arrowheads) are anastomosed with M2 and M4 portions of the middle cerebral artery, respectively. (c) Intraoperative photograph of the bypass, cervical part. The proximal end of the radial artery graft (arrow) is anastomosed with the external carotid artery. (d) Endovascular procedure. (Left) The course of the right internal carotid artery is shown through contrast medium injection from the microcatheter. (Center) Fluoroscopic imaging shows that an open-cell stent Neuroform Atlas has been deployed between markers at the both ends (arrowheads) and the first coil (arrow) is readily stabilized, being anchored by stent strut. (Right) Fluoroscopy shows that the ophthalmic segment of the right internal carotid artery is completely obliterated with coils (arrow). (e) Conventional anteroposterior and reconstructed posteroanterior view (inset) of the right common carotid angiogram show disappearance of intra-aneurysmal flow (arrow) because of parent artery occlusion with coils (arrowheads), as well as patency of the high-flow bypass. (f) Postoperative head CT scan shows that the patient's hydrocephalus improves due to the left ventriculoperitoneal shunt placement. (g) Head magnetic resonance imaging 12 months after the flow alteration therapy shows that the aneurysm is stable (arrow) with reduced perifocal edema. ACA: Anterior cerebral artery, AChA: Anterior choroidal artery, AN: Aneurysm, ECA: External carotid artery, MCA: Middle cerebral artery, OphA: Ophthalmic artery, PCoA: Posterior communicating artery, RAG: Radial artery graft.
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Schematic imaging of our treatment strategy is shown in Figure 2a. The external carotid artery-radial artery interposition graft-M2 portion of middle cerebral artery (EC-RA-M2) high-flow bypass was performed, as previously described [Figures 2b and c]. PCoA orifice [Figure 2d]. Initial coils were readily stabilized in the stent presumably because the stent strut worked as a scaffold and anchored the coils, contributing to shorter procedure time and prevention of distal coil migration. Postembolization common carotid angiography revealed complete proximal ICA occlusion, lack of contrast medium inflow into the aneurysm, and a patent high-flow bypass [Figure 2e]. She underwent ventriculoperitoneal shunt with endoscopic septostomy 3 weeks after the aneurysm treatment [Figure 2f]. She did not experience aneurysmal rupture for a year, and follow-up MRI at 6 months and 1 year [Figure 2g] revealed a stable aneurysmal size, with reduced perianeurysmal edema.