An off-label use of flow-diverter stent as a successful treatment of a postoperative middle cerebral artery pseudoaneurysm

Abstract

A pseudoaneurysm or false aneurysm is the result of the disruption of the vessel wall and the formation of a hematoma in communication with the vascular lumen, restrained by perivascular connective tissue. Intracranial pseudoaneurysms represent a rare entity mainly because of trauma, iatrogenic causes, infectious disease, radiation exposure, connective tissue disease and sometimes spontaneous occurrence. We present a 35-year-old female patient with a history of multiple low-grade glioma debulking surgeries. During the last procedure, laceration of the left middle cerebral artery (MCA) occurred with diffuse subarachnoid hemorrhage. Imaging studies showed the formation of a pseudoaneurysm of the left MCA which was successfully treated with the implantation of a flow diverter across the lesion neck and excellent mid- to long- term results. Flow diverter implantation may be a promising technique for the therapeutic management of cerebral pseudoaneurysms.

Keywords: Embolization; Flow diverter stent; Iatrogenic pseudoaneurysms; Interventional neuroradiology; Intracranial pseudoaneurysms; Middle cerebral artery.

Fig.1

Postoperative computed tomography scan shows diffuse subarachnoid hemorrhage at the level of left Sylvian fissure (arrows).

Fig. 2

Magnetic resonance imaging on day 2. The 3-dimensional time of flight sequence shows an irregularity of the M1 segment (white arrow).

Fig. 3

Computed tomography on day 7 with (A) and without (B) contrast agent. Presence of a saccular pseudoaneurysm (white arrowhead) of M1 segment of left middle cerebral artery (A) and blood in the left Sylvian fissure (B).

Fig. 4

3D digital subtraction angiography shows an increase in the size of the pseudoaneurysm now measuring 7 mm in its larger diameter (white arrows).

Fig. 5

Digital subtraction angiography before (A) and after (B) the placement of flow-diverting device (black arrowheads). After the placement there is contrast stasis inside the sac of the pseudoaneurysm (black arrow) (B). Digital fluoroscopy shows the flow-diverting device in full expansion (white arrowheads) (C).

Fig. 6

The 6-month follow-up digital subtraction angiography (A) and 3D reconstruction (B) shows complete resolution of the pseudoaneurysm and the normal blood flow in the left middle cerebral artery (white arrowheads).