case_images: PMC4109167_01
case_images: T2-weighted MR imaging shows a giant aneurysm as a flow void signal, compressing the brainstem with edema (a) Gdenhanced T1-weighted imaging shows homogeneous enhancement aneurysm (b) T2-weighted MR imaging shows a giant aneurysm as a flow void signal, compressing the brainstem with edema
case_images: SNI-5-143-g001.jpg
case_images: PMC4109167_01_SNI-5-143-g001.jpg
case_images: F1
case_images: Magnetic resonance (MR) imaging demonstrated a giant aneurysm without intraaneurysmal thrombosis that was compressing the brainstem [Figure 1].
case_images: Right vertebral angiography demonstrates a giant vertebral artery aneurysm (dome size: 42x30x30 mm). The aneurysm arises from 2 cm distal to the posterior inferior cerebellar artery orifice to vertebrobasilar junction (a,b). Left vertebral angiography shows the lumen of the contralateral left vertebral artery had a similar caliber to ipsilateral one (c). Rt. Vertebral angiography after parent artery occlusion shows complete occlusion with preservation of PICA patency (d)
case_images: SNI-5-143-g002.jpg
case_images: PMC4109167_01_SNI-5-143-g002.jpg
case_images: F2
case_images: Digital subtraction angiography (DSA) showed the aneurysm arising 2 cm distal to the posterior inferior cerebellar artery (PICA) orifice to vertebrobasilar junction, fetal-type left posterior communicating artery, and bilateral VAs of similar caliber [Figure 2a and b]. Parent artery coil embolization distal to the PICA was performed under flow control by balloon inflation at V4 portion of right VA, and complete PAO with preservation of the right PICA patency was achieved by the end of the procedure [Figure 2c and d].
case_images: Left vertebral artery angiography 14 days after parent artery occlusion shows filling of the distal side of the residual aneurysm (a). Angiography reveals complete occlusion of the aneurysm after the third coil embolization (b). Second (before; c, after; d) and third (before; e, after; f) coil embolization demonstrates complete occlusion of the aneurysm
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case_images: PMC4109167_01_SNI-5-143-g003.jpg
case_images: F3
case_images: However, one-third of the aneurysm was not thrombosed [Figure 3a]. Thirteen bare platinum coils were introduced into the aneurysm through the microcatheter, and total occlusion was confirmed at the end of this procedure [Figure 3b]. However, 1.5 months after the first coil embolization, follow-up DSA showed recurrent dome filling at the distal side of the aneurysm because of sinking of the coils into the intraaneurysmal thrombus due to pulsation effect from the VA union [Figure 3c]. Therapeutics) was placed at the union of VA through the guiding catheter introduced into the left VA. Seventeen bioactive coils were introduced into the aneurysm. The aneurysm was totally occluded [Figure 3d], but reappearance of dome filling was noted 1 month after the second embolization [Figure 3e]. Postembolization DSA confirmed total occlusion of the aneurysm [Figure 3f].
case_images: A Left vertebral angiography a month after the treatment shows complete occlusion of the aneurysm (a) MR imaging shows marked improvement in the brainstem mass effect (b) and MR angiography demonstrates no recurrence of the aneurysm at 2 years after treatment (c)
case_images: SNI-5-143-g004.jpg
case_images: PMC4109167_01_SNI-5-143-g004.jpg
case_images: F4
case_images: Follow-up DSA at 1 month [Figure 4a] after the last fourth embolization did not show recurrence of the aneurysm aside from a small neck remnant. Although no ischemic or edematous changes of the brainstem were depicted in the course of the treatment, mass effect to the brainstem gradually decreased, and her cranial nerve palsy completely resolved [Figure 4b]. Two years later, follow-up MR angiography did not show any recurrence of aneurysm [Figure 4c].