case_images: PMC10160605_01
case_images: Patient #7. A 59-year-old female experienced a Hunt and Hess 3, Fisher 4 SAH from a left proximal PICA fusiform aneurysm [(A) axial non-contrast head CT; (B) AP angiogram of the left vertebral artery (arrow highlighting aneurysm)]. She underwent a V3 to PICA bypass using a DLCFA interposition graft, followed by internal PICA aneurysm embolization. She had no strokes and an uneventful recovery. On 4-month follow was performing all activities of daily living independently. Angiogram demonstrating PICA occlusion [(C) AP left vertebral artery injection, and patent bypass (D) lateral right vertebral artery injection (arrow highlights bypass)]. (E) Post-procedural MRI (axial DWI) demonstrated no strokes.
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case_images: PMC10160605_01_fneur-14-1102496-g002.jpg
case_images: fig2
case_images: A 59-year-old female who was recovering at an outside hospital from a perforated diverticulum experienced a severe acute headache followed by a seizure and was found to have diffuse subarachnoid hemorrhage (SAH) and obstructive hydrocephalus from a ruptured left proximal PICA fusiform aneurysm (Hunt and Hess 3, Fisher 4) (Figures 2A,B). IC-IC bypass a V3 to left tonsillar PICA bypass using a DLCFA interposition graft was performed after a suboccipital craniotomy and C1 laminectomy. Immediately afterwards, the left PICA aneurysmal segment was internally embolized with coils (Figures 2C,D). She had an uneventful hospital course without complications (Figure 2E).
case_images: PMC10160605_02
case_images: Patient #8. A 61-year-old male presented with SAH and intraparenchymal hemorrhage from a previously embolized Acomm aneurysm arising from an unpaired left A1 [(A) left ICA angiogram demonstrating initial Acomm aneurysm, and after coil embolization (B); (C) head CT demonstrating SAH and IPH]. A repeat coil embolization was performed, leaving a neck residual to preserve the Acomm [(D) post re-coiling angiogram demonstrating a neck residual and patent Acomm]. An A3-A3 bypass was performed, followed by repeat aneurysm embolization with Acomm sacrifice [(E,F) post-treatment angiogram demonstrating no residual aneurysm and filling of the right ACA through the bypass (highlighted by arrows)]. (G) 3-month repeat angiogram demonstrated aneurysm re-growth and an open Acomm, treated with flow diversion across the left A1-2 and repeat aneurysm coiling (including Acomm re-sacrifice) [(H,I) post-treatment angiogram demonstrating no residual aneurysm and filling of the right ACA through the bypass (highlighted by arrows)]. On follow up, the bypass was open and there was no aneurysm recurrence. The patient was neurologically intact and living independently.
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case_images: PMC10160605_02_fneur-14-1102496-g003.jpg
case_images: fig3
case_images: Hess 2, Fisher 3) and intraparenchymal hemorrhage, with aneurysm re-growth (Figures 3A-C). A repeat coil embolization was performed, leaving a neck residual to preserve the Acomm (Figure 3D). He underwent an A3-A3 bypass followed by aneurysm embolization with Acomm sacrifice 5 days later (as the aneurysm dome was already secure), allowing for filling of the right ACA through the bypass (Figures 3E,F). He had an uneventful post-operative course and was discharged home without focal neurologic deficits. Acomm was patent (Figure 3G). A BTO was attempted to assess the bypass, however, the balloon was unable to be positioned. A1-2 and repeat aneurysm coiling (including re-sacrifice of the Acomm) was performed (Figures 3H,I). After an uneventful recovery, he was discharged home neurologically intact.
case_images: PMC10160605_03
case_images: Patient #10. A 53-year-old male was referred for a large right fusiform P2 aneurysm with a proximal dysplastic P1 vessel [(A,B) AP angiogram of the left vertebral artery]. A prior attempt at flow diversion was aborted due to unfavorable anatomy. He underwent a right OA to P4 bypass with a DLCFA interposition graft, followed by a coil embolization/vessel sacrifice of the right P2 aneurysm (keeping the proximal right P1 patent) after BTO [(C,D) serial lateral images from a right external carotid artery injection demonstrating patency of the bypass (white arrows) and backfilling of the PCA territory (black arrow)]. The right P1 was kept open to preserve perforator flow [(E) AP angiogram of the right vertebral artery (arrow highlights right P1)]. Post-operatively he experienced a small right thalamic stroke [(F) axial diffusion-weighted MRI, arrow highlighting stroke], likely from perforators off the severely diseased and sacrificed P2 segment, as well as a small right occipital stroke of unclear etiology (not shown). He had left mild hemiparesis and a partial left hemianopsia. This significantly improved on 9-month follow, where he was living at home and performing all activities of daily living independently.
case_images: fneur-14-1102496-g004.jpg
case_images: PMC10160605_03_fneur-14-1102496-g004.jpg
case_images: fig4
case_images: A 53-year-old male with a history of chronic kidney disease was referred for a large right fusiform P2 aneurysm with a proximal dysplastic P1 vessel (Figures 4A,B) after an unsuccessful attempt at flow diversion at an outside facility. This was followed by a coil embolization/vessel sacrifice of the right P2 aneurysm (Figures 4C-E). He experienced a small right thalamic stroke following aneurysm sacrifice (Figure 4F), likely from perforators off the severely diseased and sacrificed P2 segment, as well as a small right occipital stroke.