PMC4653326_01
Computed tomography angiogram three-dimensional reconstruction of the initial anterior communicating artery aneurysm as viewed from a posterior/superior angle. The right A1 (white asterisk) is dominant. The aneurysm is saccular and projects posteriorly and to the left
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F1
A computed tomography angiogram (CTA) uncovered a 3 mm ACoA aneurysm facing posteriorly with the dome directed to the left [Figure 1].
Computed tomography angiogram three-dimensional reconstruction of the anterior communicating artery complex postoperatively as viewed from a posterior/superior angle. The curved clip is seen occluding the aneurysm. There is no remnant or new aneurysm
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F2
Postoperative CTA did not reveal any residual aneurysm or DNIA [Figure 2].
Computed tomography angiogram 6 years following the initial anterior communicating artery aneurysm clipping shows the 2.5 cm x 3.7 cm x 3.0 cm giant aneurysm (white arrows). There is calcification and thrombus evident on axial (a), coronal (b) and sagittal (c) cuts. There is some filling of the aneurysm from the right A2 seen on the coronal view
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A new CTA revealed a 2.5 cm x 3.7 cm x 3.0 cm largely thrombosed, partially calcified DNIA based off of the medial wall of the right pericallosal artery [Figure 3].
Digital subtraction angiogram viewed from an anterior-oblique angle. The aneurysm is based on the medial wall of the right A2 approximately 2 mm distal to the A1-A1 junction. The anterior communicating artery, patent at the initial surgery, does not fill at all now. The aneurysm clip (red arrow) is seen in the region the anterior communicating artery aneurysm and artery to be used
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ACoA filling [Figure 4]. After a discussion of all options including surgical, endovascular observation, the patient elected to proceed with the endovascular approach. A 2.5 mm x 20 mm Flex Pipeline Embolization Device (PED; [Coviden; Plymouth, Minnesota, USA]) was deployed in the proximal right A1 extending across the aneurysm neck into the distal right A2 [Figure 5]. Angiography following stent deployment revealed immediate stagnation in the filling portion of the aneurysm.
Digital subtraction angiogram (a and b) during Pipeline Embolization Device deployment. The microcatheter can be seen traversing the right internal carotid artery, right A1 and terminating in the distal right A2. Black arrows indicate where it crosses the aneurysm base. There was stagnation noted within the aneurysm immediately following Pipeline Embolization Device placement
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F5
ACoA filling [Figure 4]. After a discussion of all options including surgical, endovascular observation, the patient elected to proceed with the endovascular approach. A 2.5 mm x 20 mm Flex Pipeline Embolization Device (PED; [Coviden; Plymouth, Minnesota, USA]) was deployed in the proximal right A1 extending across the aneurysm neck into the distal right A2 [Figure 5]. Angiography following stent deployment revealed immediate stagnation in the filling portion of the aneurysm.