Case presentation A 62-year-old patient arrived at our emergency department with a severe headache lasting about 2 hours. Initial neurological examination showed mild confusion but no motor or sensory deficits (Hunt-Hess grade 2). Cerebral CTA revealed a moderate subarachnoid hemorrhage in the pre-pontine/pre-mesencephalic region without visible vascular malformations. Subsequent angiography confirmed the absence of malformations, and the patient‘s condition gradually improved.

On the fifth day, the patient experienced a recurrent intense headache and neck stiffness. CTA showed increased subarachnoid hemorrhage volume without arterial phase malformations. A tiny hyperdense spot posterior to the distal basilar artery indicated an anterior perforating aneurysm. Angiography confirmed the aneurysm and placement of a FRED X flow-diverter (3.5 x 22 mm) from the right P1 segment to the middle basilar artery.

10 minutes before deploying the flow-diverter, a standard bolus of intravenous Cangrelor was administered, along with a 12-hour maintenance infusion. Simultaneously, intravenous Flectadol (250 mg) was given. Approximately 30 minutes after completing the Cangrelor infusion, a CTA scan confirmed stent patency and ruled out worsening subarachnoid hemorrhage. A loading dose of Brilique (180 mg) followed the scan.

Around 7 days after the procedure, the patient‘s headache completely resolved, and a follow-up CT scan showed near-complete resolution of hemorrhagic findings and stent patency. At the 1-year follow-up, the patient‘s neurological status remained normal, with patent basilar artery and right posterior cerebral artery, and no evidence of a perforating aneurysm

Disclosure of Interest nothing to disclose