case_images: PMC10834701_01
case_images: Initial diagnostic workup. CT angiogram images show the left ICA supraclinoid aneurysm and the basilar apex aneurysm: 3D reconstruction measurement, the aneurysm size was 26.4 x 21.3 mm in the left ICA supraclinoid aneurysm (A) and 20.9 x 18.1 mm in the basilar apex aneurysm (B). (C-F) Anteroposterior and lateral views of the left ICA supraclinoid aneurysm (C, D). Anteroposterior and lateral views of bilateral vertebral arteries (E, F). (G, H) 3D rotational angiography of the supraclinoid aneurysm (G) and the basilar apex aneurysm (H).
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case_images: PMC10834701_01_fneur-14-1247549-g0001.jpg
case_images: F1
case_images: In the basilar apex aneurysm with quadrifurcation of arteries, both posterior cerebral arteries and superior cerebellar artery emanate from the neck of the basilar apex aneurysm (Figure 1).
case_images: Schematic illustration of flow-diverter stents combined with flow-T stenting-assisted coiling technique. (A) Microcatheter deployed into aneurysms and bilateral posterior cerebral arteries. (B) Pipeline embolization device deployed into PCA and coils deployed through microcatheters in the aneurysm. (C) Stent placed in a T shape after the aneurysm is embolized.
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case_images: PMC10834701_01_fneur-14-1247549-g0002.jpg
case_images: F2
case_images: The technical process is depicted in Figure 2.
case_images: Stage 1. (A) Bilateral vertebral artery access (yellow arrows); (B) parent artery length, proximal and distal diameter, and aneurysm neck width were measured; (C) microguidewire-assisted microcatheter looping technique for super-select right posterior cerebral artery. The distal end of the Phenom catheter (yellow arrow); (D) distal end of the stent catheter in the left posterior cerebral artery (yellow arrow); (E) position of the coiled catheter (yellow arrow); (F) PED semi-deploying in the middle segment of the basilar artery. The anchor point of the distal end of the PED (yellow arrow); (G) densely packed upper part (black arrow) and slack coiled lower part (white arrow) of the aneurysm; (H) implanted E2 stent, achieving full expansion in front of the aneurysm neck in a T-fashion. AP (I) and lateral (J) DSA images; (K) Dyna-CT volume imaging showing the PED was fully deployed; (L) dual-volume reconstruction imaging showing all the vessels were patent.
case_images: fneur-14-1247549-g0003.jpg
case_images: PMC10834701_01_fneur-14-1247549-g0003.jpg
case_images: F3
case_images: A 5-Fr Navien catheter (Medtronic, Irvine, CA, USA) was placed in segment V3 of the left vertebral artery via a 6-Fr long sheath (Cook Medical, Indianapolis, IN, USA), while an ENVOY 6-Fr distal access guiding catheter (Codman Neuro, Raynham, MA, USA) was inserted into segment V4 of the right vertebral artery (Figure 3A). The first working position was selected, and the parent artery length, proximal and distal diameter, and aneurysm neck width were measured (Figure 3B). The Echelon-10 catheter support force facilitated the exchange of a Phenom 27 microcatheter (Medtronic) to reach the distal end of the right PCA (Figure 3C). At the second operating angle, the Prowler Select Plus microcatheter (Cordis Corporation, Bridgewater, NJ, USA) was successfully selected for the distal left posterior cerebral artery, and the Echelon-10 microcatheter was introduced and positioned in the dome of the aneurysm (Figures 3D, E). The middle and upper parts of the aneurysm were densely packed, while the lower part near the branch was loosely packed (Figure 3G). The Echelon-10 microcatheter was slowly removed, and the PED was thoroughly deployed (Figure 3H). The patient had an uneventful procedure, and recovery and remained neurologically intact (Figures 3I-L).
case_images: Stage 2. (A) Semi-deploying PED; PED anchor point (white arrow); coil catheter position (black arrow); (B) large-sized coil embolization was performed, followed by the complete deployment of the PED; (C) angiographic images reveal direct blood flow (arrow); (D) direct blood flow disappeared after further embolization of the aneurysm; (E) PED was fully deployed. (F, G) Postoperative frontal (F) and lateral (G) DSA images. (H) Dyna-CT showing the PED was fully deployed.
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case_images: PMC10834701_01_fneur-14-1247549-g0004.jpg
case_images: F4
case_images: The patient was given dual antiplatelet therapy for 6 months after the treatment and aspirin therapy for life (Figure 4).