case_images: PMC11787943_01
case_images: (A) Before clipping 3D-DSA. (B) 3D-DSA after clipping surgery. The majority of the aneurysm remained after dome clipping. (C) MRI T2WI immediately after clipping. (D) MRI T2WI 3 years after clipping. (E) MRI T2WI 6 years after clipping. Aneurysm showed enlargement over time (arrow). T2WI, T2-weighted imaging
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case_images: PMC11787943_01_jnet-19-01-2024-0088-g001.jpg
case_images: F1
case_images: Angiography revealed a 15-mm diameter aneurysm (Fig. 1A). The MCA aneurysm was clipped partially, due to the presence of significant arteriosclerosis (Fig. 1B). The residual aneurysm gradually increased in size (Fig. 1C-1E).
case_images: (A, B) MRI FLAIR 4 years after clipping axial images. Infarct foci are visible in the left cerebral hemisphere. (C, D): MRI FLAIR 8 years after clipping axial image. Aggravation of the infarcted foci in the left cerebral hemisphere is visible.
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case_images: F2
case_images: Four years after the clipping, he developed cerebral infarction in the left MCA territory and was treated at a different hospital (Fig. 2A and 2B). Eight years after the clipping, another stroke occurred in the left MCA territory, resulting in dysarthria and motor aphasia (Fig. 2C and 2D).
case_images: (A) Oblique position after 3D-DSA before FD placement. The right M2 superior trunk is occluded and M2 is seen only in the inferior trunk. (B) Oblique position after 3D-DSA before FD placement. The contrast-enhanced area had a maximum diameter of 13.3 mm. (C) MRI T2WI immediately before FD placement. The aneurysm had a maximum diameter of 27.4 mm, and the majority of it was considered to be thrombosed. (D) Frontal view of DSA before FD placement. (E) DA frontal view after FD placement. FD could be implanted at the shortest distance from M1 to M2 (arrow). DA, digital angiography; FD, flow diverter; T2WI, T2-weighted imaging
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case_images: PMC11787943_01_jnet-19-01-2024-0088-g003.jpg
case_images: F3
case_images: Cerebral angiography revealed the large left MCA aneurysm with a maximum dome diameter of 13 mm (Fig. 3A and 3B), and the left M2 superior trunk was occluded. The maximum dome diameter of the aneurysmal measured on MRI was 27 mm, and the majority of the aneurysm was thought to be thrombosed (Fig. 3C). The FRED was anchored at the M2 segment, and the system pull technique was used to obtain the shortest possible course within the mass and deployed at the proximal M1 segment to the aneurysm (Fig. 3D and 3E). After deployment of the FD, cone beam CT was performed using a 5-fold diluted contrast medium to evaluate the apposition of the FD.
case_images: (A) T2-weighted MRI 1 month after FD placement. (B) T2-weighted MRI 1 year after FD placement. No change in the size of the thrombosed aneurysm (arrow). (C) 3D-DSA frontal view before FD placement. (D) 3D-DSA frontal view at 6 months after FD placement. Complete occlusion was observed (OKM grade D). FD, flow diverter; OKM grade, O'Kelly-Marotta grading scale
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case_images: F4
case_images: Post-discharge course: MRI was performed 1 month and 1 year after discharge, but no significant change was observed, including in the size of the thrombosed aneurysm (Fig. 4A and 4B). Angiography was performed 6 months after the surgery, and complete occlusion of the aneurysm O'Kelly-Marotta grading scale (OKM) Grade D was confirmed (Fig. 4C and 4D).
case_images: (A) Cone beam CT using a 5-fold diluted contrast medium immediately after FD placement revealed vascular lumen diameters of 3.3, 3.5, and 2.9 mm at the proximal, neck, and distal segments, respectively. (B) Frontal view at 6 months after FD placement showed vascular lumen diameters of 2.7, 3.1, and 1.9 mm at the proximal, neck, and distal segments, respectively. It was thought to be due to endothelialization at the site of FD placement. FD, flow diverter
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case_images: PMC11787943_01_jnet-19-01-2024-0088-g005.jpg
case_images: F5
case_images: Comparing the vascular lumen diameter inside the FD immediately after placement and 6 months later, the lumen was reduced in diameter in the proximal, mid, and distal portions of the FD, suggesting endothelialization of the device (Fig. 5A and 5B).