A 56-year-old female with a giant partially thrombosed unruptured carotid-ophthalmic aneurysm was treated with a Pipeline flow diverter. Three months after the procedure, in concomitance with the discontinuation of one of the antiplatelet medications, the patient suffered from a minor stroke and relapsing transient ischemic attacks. The angiography demonstrated the occlusion of the internal carotid artery, and a perfusion-weighted CT scan showed a condition of hypoperfusion. The patient underwent a double-barrel extraintracranial bypass. The postoperative course was uneventful and she has experienced no further ischemic events to date.
There is increasing evidence that the flow diverters (FDs) are changing the classical treatment paradigm of cerebral aneurysms, from the occlusion of the sac to the reconstruction and healing of the vessel wall [
We describe the case of a patient who was treated with a FD for a giant internal carotid artery (ICA) aneurysm in whom an extraintracranial (EC-IC) bypass reversed a condition of ongoing cerebral ischemia caused by the FD thrombosis and consequent occlusion of the ICA.
A 56-year-old female was initially admitted to the neurosurgical department because of retroorbital pain and mild visual deterioration in both eyes. The ophthalmologic examination showed a bilateral constriction of the visual field and a slight reduction in the visual acuity on the right side. A magnetic resonance of the brain and a digital subtraction angiography (DSA) disclosed a giant partially thrombosed aneurysm of the ICA on the right side (Figure
(a) Digital subtraction angiography showing a giant carotid-ophthalmic aneurysm on the right side. (b) Coiling and flow diverter deployment. (c) Digital subtraction angiography showing the occlusion of the internal carotid artery on the right side. (d) Perfusion-weighted CT scan: reduced cerebral blood flow on the right hemisphere. (e-f) Postoperative digital subtraction angiography (early and late phases) showing the patency of the double-barrel bypass (arrows) and the territory perfused by the bypass.
(a to d) The images show the FD in different projections.
This report describes a condition where an EC-IC bypass was performed to reverse a condition of ongoing cerebral ischemia and a risk of impending stroke related to the thrombosis of a FD and parent artery occlusion (PAO). Until now, apart from a patient who underwent open surgical bailout with STA-MCA bypass and intentional ICA sacrifice to relieve optic chiasm compression after unsuccessful treatment of a giant ICA aneurysm with a FD [
The FD represents the most significant evolution of the endovascular approach for cerebral aneurysms. Although this device is undoubtedly appealing as it overcomes some of the limitations of the conventional endovascular procedures, this approach is not without drawbacks. A recent multicentric retrospective study has reported a mortality rate of 5.9% and a morbidity rate of 3.7% for a series of unruptured aneurysms [
Intrastent thrombosis and PAO, though not always clinically symptomatic, account for a significant part of the mortality and morbidity rates imputable to cerebral ischemia. Berge et al. [
It should be pointed out that, as in our patient, FD thrombosis may happen even several months after deployment, and it may be related to the discontinuation of the antiplatelet therapy. While, on the one hand, this observation emphasises the importance of long-term treatment with antiplatelet medications, on the other hand, it suggests a possible drawback that may affect the long-term risk profile of the FDs. In particular, recent data regarding patients with myocardial infarction have shown that adherence to antiplatelet medications may change during long-term therapy and problems with compliance are not uncommon [
The pathogenesis of cerebral ischemia in PAO may be thromboembolic or haemodynamic or a combination of the two. At the present time, in acute PAOs with thrombosis of vital perforating arteries or massive thromboembolic events, there are limited treatment options apart from medical therapy. A completely different condition occurs when the ischemic symptoms are, at least in part, of haemodynamic origin as in our patient. The recent COSS trial [
In conclusion, one of the possible complications related to the use of the FDs is cerebral ischemia caused by FD thrombosis and PAO. In a subgroup of patients with PAO the cerebral ischemia may be of haemodynamic origin. It is important to promptly identify this subgroup of patients as an EC-IC bypass may prevent stroke-related neurological deterioration.
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All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interests; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this paper.
The authors would like to thank Alida Scolari and Mario Lanterna for their important advice.