PMC9699869_01
(a) Early filling of PTA (red arrow) from ICA injection (b) filling of the ophthalmic segment ICA aneurysm (black arrow), PTA (red arrow), and upper extent of basilar artery (c) ICA injection image showing filling of posterior circulation (yellow arrow) through the PTA (d) ICA injection image showing filling of PTA with upper extent of basilar artery (blue arrow) and bifurcation into posterior cerebral arteries (postoperative image with coiled aneurysm seen).
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F1
A persistent trigeminal artery communicating between cavernous portion of the left internal carotid artery (ICA) and basilar artery was noticed [Figure 1]. The presence of PTA was confirmed on injection of ICA [Figure 1] and vertebral artery injection [Figures 2a-c].
(a) Subtracted angiography image showing vertebral artery injection filling the PTA (black arrow) and cavernous segment of ICA, (b) sequential angiography image showing filling of ICA ophthalmic segment of ICA and faint filling of aneurysm (red arrow) via the PTA (black arrow), and (c) sequential angiography image showing filling of anterior circulation (black arrow) via PTA, after a vertebral injection.
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F2
The presence of PTA was confirmed on injection of ICA [Figure 1] and vertebral artery injection [Figures 2a-c].
(a) A 3D reconstructed image showing size measurement of the ophthalmic segment ICA aneurysm (hollow white downward arrow) and presence of PTA filling the basilar trunk and bifurcation (solid white arrows) and (b) a 3D reconstructed image showing the saccular morphology of the aneurysm (hollow white arrow).
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F3
A three-dimensional reconstruction showed the aneurysm of size 11.2 x 5.5 mm along with presence of PTA filing the upper extent of basilar artery and posterior cerebral artery bifurcation [Figures 3a and b]. The aneurysm was saccular in morphology [Figure 3b].
(a) Unsubtracted angiography image showing presence of pipeline flex flow diverter (hollow black arrow) across ICA ophthalmic segment and presence of coils (red arrow) within the aneurysmal space. The pipeline device is carefully deployed so that it stops distal to the origin of PTA (shown with blue arrow toward the black marker of coil). The proximal end of pipeline device is shown with a solid yellow arrow and (b) solid black arrow has been cited in the text of legend as intact PTA draining into upper basilar trunk and posterior circulation. Blue arrow in figure corresponds to proximal coil marker at the level of origin of PTA from ICA.
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F4
A 5 mm x 16 mm size pipeline flex flow diverter device was deployed across the aneurysmal ophthalmic ICA segment [Figure 4a] and coils of microsphere 4 mm x 7.5 cm, two target -360 coils: 4 mm x 15 cm and one target helical ultra 3 mm x 8 cm were gradually placed into the aneurysm sac [Figure 4b].
(a) Preoperative lateral angiography image showing the ICA aneurysm (red arrow), (b) preoperative anteroposterior view showing the ICA aneurysm (red arrow), and (c) postoperative lateral angiography image showing coiled aneurysm(blue arrow). A doubt of residual filling seen along the anterior border of aneurysm did arise after this image (d) subsequent anteroposterior image showing complete occlusion of the aneurysm (blue arrow) with no residual filling. The doubt of residual filling on lateral image was clarified as an overshadow of anterior cerebral artery circulation here.
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F5
A follow-up angiogram at 6 months demonstrated complete occlusion of the left ICA aneurysm [Figure 5] and no residual filling or intrastent stenosis was noticed.
(a) A 3D reconstructed image showing presence of coils (hollow white arrow) and ophthalmic segment ICA aneurysm in the right ICA (solid white arrow) and (b) 3D reconstructed image showing 3.5 x 1.5 mm aneurysm in the right ICA-ophthalmic segment (solid white arrow).
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F6
ICA [Figure 6a]. It measured 3.5 mm x 1.5 mm [Figures 6a and b]. It was decided to follow the patient with serial angiograms.
(3D reconstructed images presented) (a) Morphology of the right ICA ophthalmic segment aneurysm (hollow white arrow) seen in follow-up angiography - two blebs seen measuring 2.2 mm and 3.1 mm and maximum base measurement 5.4 mm and (b) appearance of the right ICA aneurysm (white arrow) as seen with base measurement 5.1 mm.
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F7
Progression of the right supraclinoid ICA aneurysm in size and morphology was noticed [Figures 7a and b].
Postoperative follow-up angiography image (unsubtracted) showing right ICA SURPASS flow diverter (hollow black arrows) and left ICA pipeline flex flow diverter (hollow green arrows) along with the presence of coils.
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F8
A single SURPASS flow diverter device measuring 5 mm x 20 mm was placed across the right supraclinoid ICA aneurysm origin [Figure 8 - black arrows].
(a) Postoperative 3D reconstructed image showing appearance of the right ICA ophthalmic segment and (b) postoperative 3D reconstructed image showing a small residual aneurysm on ICA ophthalmic segment as seen pointed out by the solid white arrow.
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F9
ICA [Figures 9a and b]. It was decided to conservatively manage this residual aneurysm with subsequent angiography.