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Mural destabilization after aneurysm treatment with a flow-diverting device: a report of two cases
  1. Timothy Hampton1,
  2. Donal Walsh1,
  3. Christos Tolias1,
  4. David Fiorella2
  1. 1Department of Cerebrovascular and Endovascular Neurosurgery, King's College Hospital, London, UK
  2. 2Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook, New York, USA
  1. Correspondence to David Fiorella, Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook, NY 11794-8122, USA; dfiorella{at}notes.cc.sunysb.edu

Abstract

Background Flow-diverting stents have demonstrated great promise for the treatment of cerebral aneurysms; however, clinical experience with the devices remains very preliminary. We present two cases of spontaneous delayed complications—one fatal aneurysm rupture and one symptomatic increase in aneurysm volume—following the treatment of intradural aneurysms with the Pipeline Embolization Device (PED).

Presentation/intervention Two patients with unruptured, intradural aneurysms of the carotid artery underwent uneventful treatment with the PED (eV3, Irvine, California, USA). One patient, with a giant aneurysm of the carotid terminus, experienced worsening headache 5 days after the procedure and ultimately collapsed and became unresponsive. CT of the head demonstrated acute subarachnoid and intraventricular hemorrhage. The patient died the following day. A second patient with a large left posterior communicating artery aneurysm presented with progressive memory loss 3 months after PED reconstruction of the carotid artery. Although serial CT angiograms showed progressive thrombosis of the aneurysm to near-complete occlusion, MR of the brain demonstrated marked interval growth of the collective aneurysm–intra-aneurysmal thrombus mass with extensive edema throughout the adjacent left temporal lobe.

Conclusions Flow-diverting devices have demonstrated tremendous promise for the treatment of complex, unruptured cerebral aneurysms. However, experience with this novel approach to aneurysm treatment is preliminary and the consequences of its application within the cerebrovasculature remain incompletely defined. Mural destabilization resulting in delayed, spontaneous, aneurysm growth and/or rupture may occur in the days to weeks following the application of flow-diverting devices to treat previously unruptured intracranial aneurysms. A better understanding of the incidence and etiology of these complications is essential for this technology to be optimally applied.

  • Aneurysm
  • complication
  • device
  • hemorrhage
  • pipeline embolization device
  • spontaneous rupture
  • stent

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Footnotes

  • Competing interests Dr Fiorella is an unpaid consultant and proctor for ev3/Chestnut Medical.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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