Article Text

Download PDFPDF
Case series
‘Plug and pipe’ strategy for treatment of ruptured intracranial aneurysms
  1. Brian M Howard1,2,
  2. Jason M Frerich1,
  3. Thomas P Madaelil2,
  4. Jacques E Dion3,
  5. Frank C Tong1,2,
  6. C Michael Cawley1,2,
  7. Jonathan A Grossberg1,2
  1. 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2 Department of Radiology and Imaging Sciences, Division of Interventional Neuroradiology, Emory University School of Medicine, Atlanta, Georgia, USA
  3. 3 MicroVention, Inc, Aliso Viejo, California, USA
  1. Correspondence to Dr. Brian M Howard, Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA; brian.howard{at}


Background Aneurysmal subarachnoid hemorrhage is a potentially devastating condition, and among the first priorities of treatment is aneurysm occlusion to prevent re-hemorrhage. An emerging strategy to treat patients whose aneurysms are not ideal for surgical or endovascular treatment is subtotal coiling followed by flow diversion in the recovery phase or ‘plug and pipe’. However, data regarding the safety and efficacy of this strategy are lacking.

Methods A retrospective cohort study was performed to evaluate the efficacy and safety of ‘plug and pipe’. All patients with a ruptured intracranial aneurysm intentionally, subtotally treated by coiling in the acute stage followed by flow diversion after recovery, were included. The primary outcome was re-hemorrhage. Secondary outcomes included aneurysm occlusion and functional status. Complications were reviewed.

Results 22 patients were included. No patient suffered a re-hemorrhage, either in the interval between coiling and flow diversion or in follow-up. The median interval between aneurysm rupture and flow diversion was 3.5 months. Roy–Raymond (R-R) class I or II occlusion was achieved in 91% of target aneurysms at the last imaging follow-up (15/22(68%) R-R 1 and 5/22(23%) R-R 2). Complications occurred in 2 (9%) patients, 1 of which was neurological.

Conclusions Overall, these data suggest that subtotal coiling of ruptured intracranial aneurysms followed by planned flow diversion is both safe and effective. Patients who may most benefit from ‘plug and pipe’ are those with aneurysms that confer high operative risk and those whose severity of medical illness increases the risk of microsurgical clip ligation.

  • aneurysm
  • flow diverter
  • hemorrhage
  • subarachnoid

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • BMH and JMF contributed equally.

  • Contributors BMH and JAG: study design, data collection, data analysis, drafting of the manuscript, revision and final approval of the manuscript, and study supervision. JMF and TPM: study design, data collection, and revision and final approval of the manuscript. JED, FCT, and CMC: study design, revision and final approval of the manuscript, and study supervision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The study was approved by the institutional review board of Emory University.

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

  • Data sharing statement Any data analyzed for this study are available upon request from the corresponding author.