Rapid delayed growth of ruptured supraclinoid blister aneurysm after successful flow diverting stent treatment

Abstract

A 62-year-old woman presented with a subarachnoid hemorrhage secondary to a ruptured right supraclinoid internal carotid artery blister aneurysm. She was treated in an emergent fashion with two flow diverting pipeline embolization devices (PED) deployed in a telescoping fashion. CT angiography performed for unrelated reasons at 7 months showed successful treatment of the aneurysm without evidence of residual aneurysm. However, a follow-up digital subtraction angiogram performed at 9 months showed a large aneurysm in a modified position compared with the original aneurysm. This is the first case of rapid regrowth of a supraclinoid blister aneurysm after successful treatment with a PED, and demonstrates the need for close follow-up for similar aneurysms treated with this novel device.

Keywords: Aneurysm; Device; Flow Diverter; Subarachnoid.

Figure 1

Initial non-contrast CT (A, B) showing grade 4 subarachnoid hemorrhage, predominantly in the right suprasellar cistern. CT angiogram (C, D) showing a 2 mm blister involving the right supraclinoid internal carotid artery (arrow).

Figure 2

Cerebral angiogram of the right internal carotid artery (ICA) (frontal image (left) and three-dimensional image (right)), showing significant interval growth of the right supraclinoid ICA aneurysm.

Figure 3

Final digital subtraction angiogram image after placing two telescoping pipeline flow diverters with good aneurysm neck coverage. Arrows demonstrate proximal and distal ends of the stent.

Figure 4

Right internal carotid artery digital subtraction angiogram on day 13 showing no enlargement of the pseudoaneurysm (arrow).

Figure 5

Seven month follow-up CT angiogram showing no residual aneurysm.

Figure 6

Nine month follow-up digital subtraction angiogram shows recurrence of the right supraclinoid internal carotid artery aneurysm (arrow, A). Post deployment of the third pipeline flow diverter with contrast stagnation within the aneurysm (B).