Treatment of Intracranial Aneurysms by Functional Reconstruction of the Parent Artery: The Budapest Experience with the Pipeline Embolization Device

Giant infrasupraclinoid aneurysm of the right ICA. The patient presented with loss of vision due to mass effect (patient 13, On-line Table and Tables 1 and 2) and was treated with flow modification with transient thrombosis of the parent artery. A, DSA, right ICA injection, demonstrates bilobulated giant aneurysm (arrows). B, DSA, same view, following implantation of 2 coaxial PEDs, demonstrates partial in-stent thrombosis (arrow). C, DSA, same view, following tirofiban thrombolysis, demonstrates recanalization of the ICA (arrow) and significantly reduced flow within the aneurysm (broken arrow). D, Complete thrombosis of the ICA 2 days later. E, DSA, right vertebral artery injection, demonstrates good collateral circulation toward the right carotid system. No further action was taken at this time. F, Six-month follow-up angiogram demonstrates residual filling of the inferior portion of the aneurysm only (arrow).

Giant dissecting aneurysm of the basilar trunk in a 16-year-old boy presenting with mass effect and sudden onset of hemiparesis (On-line Table and Tables 1 and 2, patient 18.). A, T1-weighted sagittal MR image demonstrates a basilar trunk aneurysm with mass effect (arrow). B, DSA, left vertebral artery injection, posteroanterior view, demonstrates the aneurysm (arrow). Small arrows demonstrate the origin of both duplicated SCAs; broken arrow demonstrates the origin of the left AICA. C, Fluoroscopic image following the procedure. Large arrows demonstrate the distal (white) and proximal (black) edges of the 5 coaxial PEDs that were used to reconstruct the lumen of the BA. Small arrows demonstrate the SCAs, and the broken arrow demonstrates the AICA, which are both covered by the flow-modifying devices. D, Six-month follow-up angiogram demonstrates complete occlusion of the aneurysm and reconstruction of the BA. Small arrows represent the duplicated SCAs, and the broken arrow demonstrates the left AICA. All of them are patent. E, T1-weighted MR image 7 months after treatment demonstrates collapse of the aneurysm and resolution of the mass effect. Signal intensity void due to metal artifacts is seen in the treated section of the BA.

Results of aneurysm treatment by a combination of flow modification and additional coil packing. A and B, Nine-millimeter-diameter paraophthalmic aneurysm (arrow, B) treated with flow modification and coil packing (patient 3, On-line Table and Tables 1 and 2). C, Six-month follow-up angiogram demonstrates complete occlusion of the aneurysm with reconstruction of the parent artery. Arrows demonstrate subtraction artifacts and nonsubtracted view of the coil mass (23.3% volumetric packing attenuation); broken arrow demonstrates a single PED within the ICA.