Article Figures & Data
Figures
- Fig 1.
A 56-year-old patient 2 with a poorly opened PED requiring angioplasty. All images (unless stated) are left ICA angiograms in the lateral projection. Images A−E are day 2 after SAH. A, Subtracted image of 21-mm superior hypophyseal aneurysm. B, Nonsubtracted image demonstrates the PED in the ICA with a delivery catheter tip (black arrowhead) and jailed microcatheter tip (white arrowhead) in the aneurysm with the intention of coiling the aneurysm after PED deployment. C, Subtracted image after 2 PEDs were implanted. Despite sequential removal of both microcatheters, there is ongoing marked stenosis of the ICA with no aneurysm filling. D, Nonsubtracted image demonstrates an angioplasty balloon within the PED. Note contrast stasis in the sac. E, Subtraction image postangioplasty documents a normal-caliber ICA with a PED now fully open. Minimal dependent filling of the aneurysm (small black arrows) without discernible inflow jet is seen. Because the jailed microcatheter was removed before angioplasty, coiling of the sac is not possible. The patient did well but developed symptomatic vasospasm and right upper limb weakness and dysphasia day 8 post-SAH. Because she was being prepared for angiography with a view to angioplasty, the aneurysm reruptured and she became obtunded, requiring intubation. CT (not shown) demonstrated increased SAH, and emergency angiography was immediately performed. F, Anteroposterior subtracted DSA of the left ICA demonstrates severe M1 vasospasm. G and H, Lateral unsubtracted DSA (G) and lateral subtracted DSA (H) demonstrate aneurysm refilling with a new rupture point locule (black arrow). Balloon angioplasty and deployment of an additional PED (not shown) was performed, but the patient remained in poor condition and died 3 days later.
- Fig 2.
Acute aneurysm rupture on PED deployment. Patient 9 presented with SAH, WFNS grade 5, and a 34-mm fusiform paraclinoid aneurysm treated on day 1 with 2 PEDs. A, Anteroposterior oblique left ICA DSA demonstrates the same narrowing of the terminal ICA (black arrow) distal to the fusiform aneurysm neck. B, Two PEDs have been deployed (white arrows outlining the proximal PED, point of overlap of the 2 PEDs in the previously narrowed portion of the distal ICA, and the distal PED in the proximal MCA M1 segment). Note the aneurysm is rerupturing with contrast extravasation superior to the dome. The patient died the same day.
- Fig 3.
Nonoccluded blister aneurysm previously treated with stent/coil combination. Patient 5 presented with SAH and a blister aneurysm of the left P1/P0 segment, initially treated with a Solitare stent and coils. All images are subtracted DSA of the left vertebral artery in an anteroposterior transfacial projection. A, A 6-mm fusiform blister-type aneurysm projects inferiorly. Note the dilated basilar trunk. B, An aneurysm secured with coils passes through a nondetected Solitare stent. The black arrowhead designates the nondetached proximal marker of the stent. C, Enlarging fusiform blister aneurysm day 11 after MRA (not shown), performed the same, day demonstrates recurrence of the aneurysm. A PED has been deployed in the left P1 segment, across the aneurysm and into the basilar trunk. A microcatheter is jailed in the sac (small black arrow) precoiling. D, Postcoiling angiogram shows a secured aneurysm and good filling of left posterior cerebral artery. The patient developed vasospasm subsequently, which was treated with balloon angioplasty of the ICA and middle cerebral arteries bilaterally (not shown), and made a good recovery. E, Six-month angiogram shows some body filling contained within the coils. Note that the proximal margin of the PED (small white arrow) is proximal to the proximal marker of the stent (black arrowhead). The distal marker of the stent within the P1/P2 segment junction is also shown (black arrowhead). The patient's clopidogrel was stopped as a consequence of the change, but aspirin was continued. F, Ten-month angiogram shows a stable appearance. No action has been taken thus far, and a follow-up angiogram in 12 months is scheduled because there is a reluctance to overlap the PED in the basilar tip and trunk.
- Fig 4.
In-construct stenosis. Patient 4 lives in a remote location and has a 10-mm superior hypophyseal aneurysm treated with coils and PED 21 days post-SAH. ICA angiography in lateral projection. A, Unsubtracted image at 6 months demonstrates aneurysm occlusion with dense coil packing. Fifty percent focal stenosis within the proximal margin of the PED (black arrowhead) is seen with a longer segment of neointimal hyperplasia throughout the construct. B, Unsubtracted image at 10 months documents that focal stenosis is reduced as is the extent of neointimal hyperplasia (black arrowhead).
Tables
Patient, aneurysm, and treatment summary characteristics
Patient Sex/ Age (yr) WFNS Grade at Time of PED Days after SAH at Time of PED Placement Aneurysm Site Type Sac Size (mm) Previous Treatment No. of PEDs Additional Coils at Time of PED Clopidogrel/Aspirin (mg) Loading mRSa Aneurysm Occluded (at 6 mo) 1 M/48 1 24 Basilar trunk B 2 Nil 2 No 600/300 0 Yes 2 F/56 2 2 Superior hypophyseal S 21 Nil 3 No 600/300 6 Died 3 M/64 1 4 Basilar tip/P1 S 12 Nil 1 Yes 600/300 0 Yes 4 F/49 1 21 Superior hypophyseal S 10 Nil 1 Yes 300/300 0 Yes 5 F/52 2 11 P1/P2 B 12 Coils and stent (day 2) 1 Yes 300/300 2 Filling 6 M/51 3 26 Vertebral B 2 Nil 1 No 450/150 2 Yes 7 M/56 2 1 Basilar trunk F 21 Nil 2 Yes Long-term daily 75/100 1 Yes 8 F/50 1 16 PcomA F 12 Nil 2 No 75/150 5-Day loading 0 Yes 9 F/37 5 1 Dorsal paraclinoid ICA F 34 Nil 2 No 300/300 6 Died 10 F/64 4 8b Dorsal paraclinoid ICA B 2 Coils and stent (day 1) 1 Yes 75/150 7 Days 4 Yes 11 F/41 1 21 P1/P2 B 6 Coils (day 1) 1 No 75/150 5-Day loading 0 Yes
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