Endovascular Treatment of a Fusiform Aneurysm at the M3-M4 Junction of the Middle Cerebral Artery Using the Pipeline Embolization Device.

BACKGROUND: Peripheral fusiform cerebral aneurysms remain difficult to treat. Current surgical approaches to the treatment of fusiform aneurysms include wrapping, clip occlusion or vessel reconstruction without parent vessel sacrifice, and aneurysm trapping with or without bypass, although these may carry high morbidity (36%). Classic endovascular approaches to the treatment of peripheral aneurysms include selective or parent artery occlusion, which imparts the risk of distal infarction. It may be possible to use a flow diversion device off label to treat the aneurysm and preserve flow to the distal territory. CASE DESCRIPTION: After a presyncopal event, a patient was found to have an unruptured fusiform aneurysm at the junction of the M3 and M4 segments of the right middle cerebral artery. After initiating dual antiplatelet therapy, the aneurysm was successfully treated with a Pipeline embolization device. Three months after treatment, the aneurysm has completely thrombosed, the parent artery remains widely patent, and the patient remains at her neurologic baseline. CONCLUSIONS: Flow diversion devices may provide the neurointerventional surgeon with an opportunity to treat fusiform peripheral aneurysms and preserve flow to the distal territory.

Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. METHODS: A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. RESULTS: On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmologic complications were noted in either cohort. Complete occlusion at 12 months was more common following PED treatment than coil embolization (74% vs 47%; p=0.089), although lower than reported in previous trials. This may be due to inflow into the ophthalmic artery keeping the aneurysm patent. Retreatments were more common following coil embolization than PED (24% vs 11%), but this was not significant (p=0.304). Permanent morbidity rates were not significantly different between the PED (11%) and coil embolization (3%) cohorts (p=0.255). CONCLUSIONS: Our results suggest that ophthalmic artery aneurysms may be adequately and safely treated with either the PED or coil embolization. However, treatment with the PED carries a higher risk of impeding flow to the ophthalmic artery, although this did not result in clinical sequelae in the current study.