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Case series
Modifying flow in the ACA–ACoA complex: endovascular treatment option for wide-neck internal carotid artery bifurcation aneurysms
  1. Erez Nossek,
  2. David J Chalif,
  3. Mitchell Levine,
  4. Avi Setton
  1. Department of Neurosurgery, Hofstra North Shore–Long Island Jewish School of Medicine, and North Shore–Long Island Jewish Health System, Manhasset, New York, USA
  1. Correspondence to Dr Avi Setton, Department of Neurosurgery, North Shore–Long Island Jewish Health System, North Shore University Hospital, 300 Community Drive, 9 Tower, Manhasset, NY 11030, USA; asetton{at}nshs.edu

Abstract

Background Treatment of selected wide-neck internal carotid artery (ICA) bifurcation aneurysms remains challenging for clip reconstruction and for endovascular options.

Objective To describe a new endovascular treatment technique for wide-neck ICA bifurcation (ICAb) aneurysms.

Methods We have employed a treatment approach that uses both complete proximal occlusion and reversal of flow in the ipsilateral A1 segment, using different endovascular modalities such as coils, stent-assisted coiling, or flow diverters (FDs) plus coiling concomitantly. This endovascular technique may overcome the challenges of current treatments and high recanalization rates for coiled ICAb aneurysms.

Results We treated four patients in whom we redirected the pre-existing flow in the supraclinoid ICA into the ipsilateral A1 and M1 segments, to a new unilateral, linear flow from the supraclinoid ICA solely into the ipsilateral M1 segment. This resulted in the establishment of flow from the contralateral A1 segment into the ipsilateral A1 segment, allowing supply of only demanding perforating arteries on this specific (ipsilateral) segment. This technique was not associated with any new neurological deficits or radiographic ischemia. The four patients reviewed were all treated using coils. One was treated with a standard stent. The other two were treated with a FD.

Conclusions We found that the proposed technique of flow modification can allow for hemodynamic conversion of ICAb to ‘side-wall’ aneurysm. In patients with good collateral flow through the anterior communicating complex, this treatment paradigm is safe and effective.

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