Article Figures & Data
Figures
- FIG 1.
A, Initial NCCT showing the SAH. B, Axial MIP of the MRA. The suspected intracranial aneurysm of the anterior communicating artery (AcomA) and the posterior communicating artery (PcomA)/P1 can be seen (white arrows). C, DSA from the treatment. Left vertebral artery injection; a detailed view of the basilar artery head is shown. The blood-blister-like aneurysm of the P1 segment of the left posterior cerebral artery with the PcomA is demonstrated (white arrow), corresponding to the MRA, though smaller-appearing. D, Microcatheter injection. The tip of the microcatheter is in the distal left ICA, coming from the posterior via the PcomA. The left carotid-bifurcation is demonstrated (arrow). E, DSA after flow-diverter placement, reaching from the beginning of the P1 segment of the left posterior cerebral artery to the left PcomA, covering the left P1/PcomA angle (arrows pointing to the ends of the flow diverter). The aneurysm is no longer seen. F, Right ICA injection. The blood-blister-like aneurysm on the AcomA is identified, corresponding to the MRA. G, Unsubtracted view right after the deployment of the flow diverter from the A2 segment of the left anterior cerebral artery into the A1 segment of the right anterior cerebral artery. The delivering wire and the microcatheter are still in place. H, DSA after flow-diverter detachment. The aneurysm is covered but still filling with contrast (arrows indicate the ends of the flow diverter). I, Control angiogram left vertebral artery injection. The P1/PcomA aneurysm is occluded; the flow diverter is patent. J, Control angiogram of the right common carotid artery injection. The AcomA aneurysm is closed. The flow diverter is patent but shows a proximal shortening into the left A2 segment, just covering the site of the aneurysm (this is patient 1, Online Supplemental Data).
- FIG 2.
A, SAH primarily in the left Sylvian fissure on NCCT. The patient was Hunt and Hess 1 at that time, B, Aneurysm on the inferior trunk of the MCA, broad-based (white arrow). C, Implantation of a p48-MW-HPC flow-diverting stent from M1 into M2 (white arrows pointing to stent endings). D, DSA control 24 hours later. The flow diverter is patent; some stasis in the aneurysm is seen (white arrow). E, DSA control about 15 minutes later. Acute thrombosis developed on the superior trunk (white arrow). The flow diverter is patent. The patient had acute aphasia and hemiparesis after application of a pressure dressing in the groin. F, After therapy with IV tirofiban, the thrombosis disappeared (white arrow). The neurologic deficits resolved completely. G, After approximately 10 days, severe vasospam developed (white arrow). H, The vasospam, unfortunately, despite intense therapy, led to severe infarction of the left MCA and anterior cerebral artery territory (white arrow) (this is patient 9, Online Supplemental Data).
- FIG 3.
A, NCCT showing the SAH. B, Right vertebral artery injection. A faint extravasation around the P1/P2 segment of the right posterior cerebral artery is noted (arrow). C, Late-phase right vertebral artery injection, oblique view. The extravasation is demonstrated on the late phase (arrows). D, 3D DSA. A small outpouching at the proximal P2 segment is noted, consistent with a blood-blister-like aneurysm (arrow). E, Unsubtracted view from the treatment. The flow diverter and delivery wire are still in place. F, Final DSA run of the treatment. The flow diverter remains patent. G, Control angiography at 6 months. The flow diverter is unchanged and patent (H) (this is patient 3, Online Supplemental Data).
- FIG 4.
A, NCCT depicts an acute basal SAH. B, DSA on the day of the SAH shows no aneurysm. C, SAH rebleeding on day 5 after the initial bleed. D, NCCT now demonstrates an unusual aneurysm interpreted as a dissecting aneurysm of a basilar artery perforator (arrow). E, Treatment of the aneurysm with a hydrophilic-coated flow diverter; unsubtracted image right after deployment (arrows indicate the ends of the flow diverter). F, Subtracted image from the treatment. Slow filling of the aneurysm can be still seen (late arterial phase, arrows at the ends of the flow diverter). G, Five days after the treatment, CTA demonstrates that the flow diverter is patent (arrows). H, T2-weighted axial MR imaging 11 days after treatment. A small infarction in the territory of the aneurysm carrying the perforator can be seen (arrow). No infarcts due to the flow diverter are noted (this is patient 5, Online Supplemental Data).
Tables
Recent studies of FD treatment in acute SAH in specific conditions
Authors Publication Date Aneurysm Type No. of Patients/Mean Age Treatments Results/Occlusion Rates Complications Maus et al24 2018 Dissecting vertebrobasilar 1556 yr 15 IAs, 22 FDSs, treatment within 12 h of SAH onset 36% Directly occluded; 100% occluded on FU 3 (Ischemia, vessel perforation, ongoing active bleeding) Bhogal et al22 2018 Small IA (1–4 mm) 760 yr 7 IAs, 8 FDSs, treatment within 6.3 days from SAH (median) 100% Occluded on FU None Lozupone et al23 2018 8 BBAs, 9 dissecting IAs 174 yr 17 IAs, 21 FDs, treatment within 4.2 days (median) 12 of 15 Patients followed-up 12% Mortality;12% morbidity AlMatter et al21 2019 Saccular (18), fusiform (5), BBA (7), dissecting (15) 4558. 8 yr 45 IAs, FDSs as sole or adjunct device, treatment within 30 days after SAH 94.6% Complete occlusion on follow-up among survivors 13.3%; 2.2% Morbidity; 4.4% mortality Note:—IA indicates intracranial aneurysm; FDS, flow-diverting stent; FU, follow-up; BBA, blood-blister-like aneurysm; FD, flow diverter.
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