Case 5

Abstract

A 38-year-old man with acute subarachnoid hemorrhage. (a) NECT shows a large 3.5 × 3.0 cm, well-defined, spherical hyperdensity in the left Sylvian fissure with extensive subarachnoid hemorrhage and focal calcification. Cerebral DSA and 3D images reveal a giant 3.5 cm-sized left M1 segment MCA fusiform aneurysm with proximal stenosis. (b) On April 2011, the patient underwent treatment with a LEO® scaffold and a SILK® flow diverter within. Note the persistent, approximately 40 % stenosis in the proximal M1 segment after deployment of flow diverter. In the immediate postprocedural angiogram, due to flow diversion, the lateral lenticulostriate branches are better opacified with flow stagnation in the aneurysmal sac. Note the SILK® FD does not intentionally cover the left ACA origin. (c) After 2 h, the patient developed sudden altered sensorium, and a control angiogram reveals acute in-stent thrombosis. A balloon angioplasty with Gateway® balloon (Boston Scientific, Fremont, California) was done across the stenosis with restoration of flow. On a 24-h postprocedural angiogram, there is significant decrease in the aneurysmal opacification with good distal flow. (d) Follow-up MRI 1 month later reveals aneurysmal wall enhancement and extensive peri-aneurysmal vasogenic edema involving the frontal and temporal lobes, peri-insular region, and diencephalon. The aneurysm is thrombosed with infarctions in the lateral lenticulostriate territory and perisylvian region. (e) Control DSA at second month reveals total exclusion of the aneurysm from circulation. The aneurysm bearing M1 segment of left MCA shows focal enlargement. (f) MRI images at third month reveal thrombosed and shrunken MCA GIA. There is complete resolution of the vasogenic edema with lenticulostriate and perisylvian regional infarction. (g) Comparison of follow-up DSAs at 2 months and 3 years posttreatment reveals a patent left MCA segment. There is progressive remodeling of the carotid siphon: aneurysmal segment and M1 segment of MCA to a normal caliber. The left ACA remains patent