PMC8769381_01
Preoperative time of flight MR angiography (A), axial T1-weighted MR image (B), and axial T2-weighted MR image (C) showing a well-defined mass in close relation to the cavernous portion of the right ICA. ICA: internal carotid artery, MR: magnetic resonance.
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Magnetic resonance imaging (MRI) and MR angiogram revealed a well-defined mass adjacent to the cavernous portion of the right ICA (Fig. 1A). T1-weighted images and hypo-intense on T2-weighted images (T2WI) (Fig. 1B and 1C). The posterior part of the mass was partially hyper-intense on T2WI, and the lesion appeared to be a partially thrombosed cavernous ICA aneurysm.
(A and B) Antero-posterior view and lateral view of the right ICA angiography obtained 3 weeks before the endovascular procedures, demonstrating a large aneurysm (22 mm) in the cavernous portion of the right ICA. (C and D) Antero-posterior view of the left ICA angiography and lateral view of the right vertebral artery angiography with compression of the right carotid artery (compression study), demonstrating collateral blood supply from the posterior circulation to the right ICA through the right posterior communicating artery. ICA: internal carotid artery.
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ICA (Fig. 2A and 2B). In compression study, collateral circulation from the contralateral ICA through the anterior communicating artery was not confirmed; however, collateral blood supply from the posterior circulation through the right posterior communicating artery was confirmed (Fig. 2C and 2D).
(A) DSA obtained on the day of endovascular treatment showing a rapid growth of the intra-aneurysmal thrombosis (arrow heads) and the de novo thrombosis in the parent artery (arrow). (B) Direct aspiration of the thrombus in the parent artery via a distal support catheter (arrow) with proximal blood flow arrest using a balloon-guide catheter (double arrow). (C) Most of the thrombus in the parent artery was removed (arrow). (D) High-resolution computed tomography image showing sufficient apposition of the FD stent to the right ICA. (E and F) Antero-posterior view and lateral view of the postoperative DSA showing good antegrade blood flow to the distal territory. DSA: digital subtract angiography, FD: flow-diverting, ICA: internal carotid artery.
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Right ICA angiography conducted in advance of delivery of the PED demonstrated a filling defect of contrast material in most of the aneurysm and the siphon of the right ICA (Fig. 3A). Direct aspiration of the thrombus via a 5-F Navien distal support catheter (Covidien/eV3 Neurovascular) was performed with proximal blood flow arrest using a balloon-guide catheter (Fig. 3B). Most of the thrombus was removed by this procedure (Fig. 3C). The PED (Covidien/eV3 Neurovascular) was successfully deployed via a Marksman microcatheter (Covidien/eV3 Neurovascular) to cover the neck of the aneurysm in a state in which proximal blood flow arrest was continued (Fig. 3D-3F).
(A and B) Antero-posterior view and lateral view of the DSA obtained 12 months after the treatment showing complete occlusion of the aneurysm. DSA: digital subtract angiography
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DSA obtained at 12 months after the procedure demonstrated complete occlusion of the aneurysm (Fig. 4A and 4B).