Giant and Large Peripheral Cerebral Aneurysms: Etiopathologic Considerations, Endovascular Treatment, and Long-Term Follow-Up
A. Biondia,
B. Jeana,
E. Vivasa,
L. Le Jeanb,
A.L. Bochc,
J. Chirasa and
R. Van Effenterrec
a Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University School of Medicine, Paris, France
b Department of Anesthesiology, Pitié-Salpêtrière Hospital, Paris VI University School of Medicine, Paris, France
c Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris VI University School of Medicine, Paris, France
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Fig 1. Partially thrombosed giant aneurysm of the superior branch of the right MCA bifurcation in a 64-year-old woman presenting with headache and paresis of the left arm.
A and B, CT scans with contrast injection show a giant heterogeneous right temporal lesion with a "cystic" compartment, calcifications, and severe mass effect. C, Coronal T2-weighted MR image shows an unusual aspect of a partially thrombosed giant aneurysm of a right MCA branch. The right internal carotid artery angiography, in anteroposterior (D) and lateral (E) views, depicts the patent compartment of the aneurysm. F, Occlusion test with a nondetachable balloon. On the angiographic venous phase in the lateral view, a retrograde filling of the arterial branches after the level of the occlusion (arrows) is observed via leptomeningeal anastomosis. G, Three days after the PAO was performed by using coils, a CT scan without injection of contrast shows shrinkage of the aneurysm and reduction of the mass effect. H, A CT scan with injection after 1.5 years shows persistent disappearance of the mass effect and reduction of the thrombosed compartment in relation to the CT examination performed after 6 months (not shown). I, Angiographic 1.5-year follow-up of the right internal carotid artery in the anteroposterior view shows persistent exclusion of the aneurysm and retrograde vascularization of the vessels beyond the occlusion via leptomeningeal anastomosis from ACA and MCA branches. Arterial supply from the PCA was also observed on the vertebral angiogram (not shown). In follow-up studies after 3.5 years, CT scans (J and K) and coronal T2-weighted MR image (L) show further shrinkage of the aneurysmal thrombosed compartment. Findings of the neurologic examination were normal.
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Fig 2. Partially thrombosed giant aneurysm of the P2-P3 segment of the left posterior cerebral artery in a 28-year-old woman presenting with headache and loss of consciousness.
A and B, CT scans with injection of contrast show a large lesion compatible with the diagnosis of a thrombosed aneurysm. C, Oblique view of the left vertebral artery angiography shows the circulating portion of the aneurysm associated with a slight stenosis of the parent artery. Slow filling of the parent artery beyond the aneurysm is noted (arrow). D, Intermediate step of the endovascular procedure. After occlusion of the P2-P3 segment of the posterior cerebral artery by using coils, anteroposterior (E) and lateral (F) views of the left internal carotid artery angiography show the retrograde vascularization of the PCA distal to the occlusion via the leptomeningeal anastomosis (arrows). Thirty-six hours after PAO, the patient presented with transient mild paresthesias and mild oculomotor paresis, which completely regressed in 3 days. Follow-up studies after 1 month (T1-weighted MR image, (G); and CT scan with injection of contrast, (H) show reduction of the aneurysmal thrombosed portion and reduction of the mass effect. Follow-up studies after 1 year (CT scan, (I) and after 4 years (fluid-attenuated inversion recovery MR image, (J); and CT scans, (K and L) show further shrinkage of the aneurysmal thrombosed compartment. The small left posterior thalamic infarct is well visualized (L). Findings of the neurologic examination were normal at 5-year follow-up.
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