PMC8769442_01
(A-E) The MRI scans 20 days prior to the first coil embolization indicate a signal void on the right side of the mass (A, B1, B2; TOF-MRA), surrounded by iso-intensity of the center and high-intensity peripherally of the T1-weighted images (C1, C2), heterogeneity intensity of the T2-weighted images (D1, D2), and fluid-attenuated inversion recovery (E1, E2). (F, G) Right CAG performed 15 days prior to the first coil embolization. (F) anteroposterior view, (G) left lateral view, (H) left CAG (3D DSA), left anterior-oblique view, (I) Right CAG (3D DSA), left posterior-oblique view. Acom: anterior communicating artery, CAG: carotid angiography, MRI: magnetic resonance imaging, TOF-MRA: time-of-flight magnetic resonance angiography, 3D DSA: three-dimensional digital subtraction angiography.
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F1
The MRI scans (Fig. 1A-1E) revealed a round mass, indicating a patent cavity on the right side surrounded by an intra-aneurysmal thrombus. An angiogram revealed a large Acom aneurysm (maximum diameter, 19 mm; Fig. 1F and 1G). The aneurysmal neck was located at the junction of the left A1-A2 segments, and the aneurysmal dome was communicated with the right A1-A2 junction by the Acom (Fig. 1H and 1I).
(A-E) CAGs showing the first endovascular treatment. (A, C) Left CAG; (B, D, E) Right CAG. (B) Balloon test occlusion of the left A1 segment, (C) endosaccular embolization and the internal trapping of the medial portion of the left A1 segment (black arrow). (D, E) Post-first embolization. (A-D), left-anterior oblique view; (E) antero-posterior view. (F) Illustration of the image of the first embolization. Black arrow, internal trapping of the medial portion of the left A1 segment; *, intra-aneurysmal thrombus. (G-J) Right CAGs 4 months after the first treatment. G (non-subtracted) and H (subtracted) revealed complete disappearance of the aneurysmal thrombus and remarkable recanalization. I and J show post-second embolization images. (G-I) Right anterior oblique view, (J) antero-posterior view. CAG: carotid angiography.
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Fremont, CA, USA) and GDC Detachable Coils (total length, 30 cm; Stryker, Fremont, CA, USA) (Fig. 2A-2E). Figure 2F shows the image of the first embolization. However, coil transformation was detected, and the angiogram at 4 months following the first embolization revealed the complete disappearance of the intra-aneurysmal thrombus and marked aneurysmal recanalization (Fig. 2G and 2H). Subsequently, we performed a second coil embolization through the Acom route (Fig. 2I and 2J).
(A-D) Right CAGs showing the third embolization 3 years after the first embolization, antero-posterior view. A (non-subtracted) and B (subtracted) showing the aneurysmal recanalization. C (non-subtracted) and D (subtracted) showing the post-third embolization. (E) Illustration showing a recent image of the aneurysm. (F, G, I) TOF-MRA images of the next day (F), 4 years (G), and 7 years (I) following the third embolization. (H, J) Plane X-ray of 4 years (H) and 7 years (J) following the third embolization. CAG: carotid angiography, TOF-MRA: time-of-flight magnetic resonance angiography.
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We also performed a third embolization 3 years following the first embolization (Fig. 3A-3D). Figure 3E indicates the aneurysmal image following the last embolization. MRI (Fig. 3F, 3G, and 3I) and plane X-ray imaging (3H, 3J) were performed during the follow-up of 7 years following the last embolization. Although we observed gradual neck recanalization following the third embolization, we did not opt for an additional coiling owing to the small remnant space and good clinical signs, and the absence of recanalization progress for 3 years (Fig. 3F-3J).
(A-F) Perimetry charts of the Humphrey (A-D) and the Goldmann (E, F). (A, B) 1 month; (C, D) 2 years; (E, F) 10 years following the first embolization. Comparing between the perimetry C-D and E-F within the circle range of 30 degree (black arrows), the area of improved bitemporal hemianopsia was maintained for 8 years. VA: visual acuity.
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 Figure 4 shows the time course of visual acuity and perimetry. Figure 4A and 4B (Humphrey), at 43 days following the first embolization, indicates bitemporal hemianopsia predominantly in the right eye. Figure 4C and 4D (Humphrey), at 2 years, and 4E and 4F (Goldmann) at 10 years, indicates that favorable visual function results maintained the improved bitemporal hemianopsia in the range of 30 degree.