PMC9676233_01
Anteroposterior (A) and lateral (B) digital subtraction angiography views and three-dimensional reconstruction angiography (C) revealed a large saccular right supraclinoid internal carotid artery aneurysm. Maximum diameter was 17.7 mm and the aneurysm neck was 7.06 mm. Anteroposterior (D), lateral (E), and operating position (F) angiographic views immediately after placement of a Pipeline Flex embolization device (Medtronic, Dublin, Ireland) showed contrast filling in the aneurysm lumen with entry remnant (O'Kelly-Marotta Grade C).
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F1
Cerebral angiography confirmed a large right supraclinoid ICA aneurysm (Figures 1A-C). Irvine, CA)) were deployed through the Echelon-10 microcatheter. Immediately after coiling, angiography showed near-complete occlusion with entry remnant (O'Kelly-Marotta grade C) and Dyna-computed tomography (Dyna CT) showed no SAH or ICH (Figures 1D-F, 2A).
Dyna computed tomography immediately after the procedure (A) showed no subarachnoid hemorrhage or intracerebral hemorrhage. Emergency head computed tomography 11 h after the procedure (B) showed a small amount of hemorrhage in the Sylvian cistern, anterior interhemispheric cistern, and lateral ventricle.
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F2
Irvine, CA)) were deployed through the Echelon-10 microcatheter. Immediately after coiling, angiography showed near-complete occlusion with entry remnant (O'Kelly-Marotta grade C) and Dyna-computed tomography (Dyna CT) showed no SAH or ICH (Figures 1D-F, 2A). Emergency head CT showed SAH in the right Sylvian cistern, anterior interhemispheric fissure, and lateral ventricle (Hunt-Hess grade IV; modified Fisher grade 2; Figure 2B).
Anteroposterior (A) and lateral (B) views of cerebral angiography showed a small amount of blood flow into the aneurysm lumen (white arrows), suggesting delayed aneurysm rupture. Placement of a Willis covered stent (MicroPort, Shanghai, China) was then performed. Anteroposterior (C) and lateral (D) views of angiography performed immediately after the procedure showed no residual blood flow in the aneurysm lumen. The internal carotid and anterior choroidal arteries were patent.
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F3
Delayed aneurysm rupture was considered as the cause, and digital subtraction angiography showed that there was still a small amount of blood flow into the lumen of the aneurysm, suggesting the location of delayed aneurysm rupture here (Figures 3A,B). Angiography immediately after deflation of the balloon showed no aneurysmal filling and parent artery patency (Figures 3C,D).
Computed tomography of the head on day 1 after covered stent placement (A) showed no progression of subarachnoid hemorrhage or other obvious abnormality. Magnetic resonance angiography of the brain on day 6 (B) showed the aneurysm was completely occluded (white arrow) and the parent artery was patent.
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F4
The patient was extubated on the subsequent day after repeat head CT showed no progression of SAH (Figure 4A). Magnetic resonance angiography 6 days after treatment demonstrated parent artery patency and no aneurysmal filling (Figure 4B).