PMC7213518_01
Giant, non-ruptured, 50 mm left PCoA aneurysm that persisted after initial endovascular treatment. (A) DSA (lateral view) of left internal carotid artery demonstrating partial filling of a persistent giant PCoA aneurysm treated first with stent-assisted coiling followed by flow diversion with the pipeline embolisation device. (B) DSA (lateral view) of left vertebral artery demonstrating partial filling of the aneurysm from the posterior circulation in mid-arterial (B) and late-arterial (C) phases. DSA, digital subtraction angiogram; PCoA, posterior communicating artery.
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F1
ICA terminating in the persistent giant PCoA aneurysm (figure 1A). In addition, the PCoA aneurysm also filled during posterior circulation injections (figure 1B and C).
MRI reveals a mass lesion with brainstem compression. Axial cranial T2 MRI demonstrating a partially thrombosed persistent giant PCoA aneurysm causing brainstem compression. MRI, magnetic resonance imaging; PCoA, posterior communicating artery.
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F2
Direct compression of the aneurysm on the descending corticospinal tracts in the brainstem was believed to be the cause of the patient's subacute contralateral neurological decline and warranted treatment (figure 2).
Microsurgical aneurysm debulking and clipping following endovascular coil occlusion of left internal carotid artery for treatment of a persistent giant PCoA aneurysm. Intraoperative image with the pipeline embolisation device flow diverter visualised through the debulked PCoA aneurysm dome. PCoA, posterior communicating artery.
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F3
The aneurysm dome was debulked revealing multiple embolisation coils, associated thrombus and the prior PED was visualised in the parent ICA (figure 3).
Postoperative cerebral angiography following endovascular coiling of the left internal carotid artery and microsurgical aneurysm debulking and clipping of a giant left PCoA aneurysm. Postoperative angiography of the (A) right lateral internal carotid artery and (B) vertebral artery cerebral demonstrating complete occlusion of the giant PCoA aneurysm. PCoA, posterior communicating artery.
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F4
PCoA. Postoperative angiogram confirmed no residual aneurysm filling from either anterior or posterior circulation (figure 4A and B) and delayed postoperative MRI demonstrated significant decompression of the brainstem (figure 5).
Delayed postoperative MRI following endovascular coiling of the left internal carotid artery and microsurgical aneurysm debulking and clipping of a giant left PCoA aneurysm. Delayed postoperative axial T2 MRI demonstrating the residual coil mass in a thrombosed giant PCoA aneurysm, with significant reduction in brainstem compression compared with preoperative MRI. Artifact from coil mass and aneurysm clips. MRI, magnetic resonance imaging; PCoA, posterior communicating artery.
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F5
PCoA. Postoperative angiogram confirmed no residual aneurysm filling from either anterior or posterior circulation (figure 4A and B) and delayed postoperative MRI demonstrated significant decompression of the brainstem (figure 5).