case_images: PMC10601690_01
case_images: DSA: lateral view. A giant wide-neck matricidal CCA (yellow arrow) of the left ICA (red arrow) is depicted with a moderate-outflow stenosis (white arrow).
case_images: crn-2023-0015-0001-533832_F01.jpg
case_images: PMC10601690_01_crn-2023-0015-0001-533832_F01.jpg
case_images: F1
case_images: The interventional radiologist could not bridge the aneurysm with a microcatheter by the orthograde approach due to a stenosis in the outflow segment of the left ICA distal to the aneurysm (Fig. 1).
case_images: DSA: anteroposterior view, road map. The yellow arrow points at the passive catheter introduced in a transcirculation fashion into the AN. The red arrow points at the position of the active catheter while pulling the lasso catheter (white arrow) through the outflow stenosis. A substantial change of arterial anatomy during the unsuccessful procedure on the image is well depicted - compare the position of passive versus active catheter. As a consequence of these anatomical changes, a bleeding from torn-off perforator occurred.
case_images: crn-2023-0015-0001-533832_F02.jpg
case_images: PMC10601690_01_crn-2023-0015-0001-533832_F02.jpg
case_images: F2
case_images: The outflow stenosis of the left ICA made any attempt (to bridge the aneurysm and implant the stent) unsuccessful (Fig. 2).
case_images: DSA: anteroposterior view. Balloon occlusion test with good filling of left anterior and middle cerebral arteries (yellow arrow) from the right ICA via the anterior communicating artery. Matricidal CCA (red arrow).
case_images: crn-2023-0015-0001-533832_F03.jpg
case_images: PMC10601690_01_crn-2023-0015-0001-533832_F03.jpg
case_images: F3
case_images: ICA with adequate collateral blood supply on angiography without clinical presentation (Fig. 3). In such circumstances, deconstructive treatment by occluding the left ICA with the coiling of the aneurysm seemed to be safe and planned for the next session.
case_images: DSA: anteroposterior view. Occlusion of the A1 segment of ACA (yellow arrow).
case_images: crn-2023-0015-0001-533832_F04.jpg
case_images: PMC10601690_01_crn-2023-0015-0001-533832_F04.jpg
case_images: F4
case_images: A1 segment of the left anterior cerebral artery (ACA). An immediate coiling of the segment was performed (Fig. 4).
case_images: DSA: lateral view. Angiographic image of direct carotid-cavernous fistula. Ophthalmic vein (yellow image), inferior petrous sinus (red arrow).
case_images: crn-2023-0015-0001-533832_F05.jpg
case_images: PMC10601690_01_crn-2023-0015-0001-533832_F05.jpg
case_images: F5
case_images: DSA revealed the direct carotid cavernous fistula with a typical venous outflow to the petrosal and cavernous sinus and the ophthalmic vein (Fig. 5).
case_images: DSA: anteroposterior view. Coiled matricidal CCA (yellow arrow), confined filling of bypass (red arrow), filling of the middle cerebral artery (white arrow).
case_images: crn-2023-0015-0001-533832_F06.jpg
case_images: PMC10601690_01_crn-2023-0015-0001-533832_F06.jpg
case_images: F6
case_images: DSA showed only low blood flow in the arterial graft (Fig. 6).
case_images: DSA: anteroposterior view. Angiography showing a more significant filling of the high-flow bypass (red arrow) and the middle cerebral artery (white arrow).
case_images: crn-2023-0015-0001-533832_F07.jpg
case_images: PMC10601690_01_crn-2023-0015-0001-533832_F07.jpg
case_images: F7
case_images: DSA and CTA indicated good blood flow in the arterial graft with significant blood filling of the middle cerebral artery branches (Fig. 7, 8).
case_images: CTA; 3D reconstruction shows filling of the left ICA and high-flow bypass.
case_images: crn-2023-0015-0001-533832_F08.jpg
case_images: PMC10601690_01_crn-2023-0015-0001-533832_F08.jpg
case_images: F8
case_images: DSA and CTA indicated good blood flow in the arterial graft with significant blood filling of the middle cerebral artery branches (Fig. 7, 8).