Transient Gerstmann syndrome following flow diversion of a giant left ophthalmic artery aneurysm: a case report

• Main complaint: agraphia one day after flow diversion treatment
• 57-years-old female patient
• Other complaints:
  • acalculia, finger agnosia, and hemineglect one day after treatment
• History of disease: sporadic severe headache for 8 years

CT angiography

 DSA 3D

Dome neck ratio: 2.51: 1.01 2.49  /  Flow diverter working length

DSA LICA AP pre vs post flow diversion

Pre flow diversion 

Post flow diversion

CT brain evaluation 3 hours after onset

DSA LICA proximal spasm

Pre papaverin

Post papaverin

0,5  - 6 % cases
Mostly asymptomatic,  underdiagnosed

Hakma Z, Ramaswamy R, Loftus C. Mortality rates for giant aneurysms. Acta Neurochirurgica. 2011;153(8):1621-1623 .

Zheng Y, Zhou B, Wang X, Chen H, Fang X, Jiang P, et al. Size, aspect ratio and anatomic location of ruptured intracranial aneurysms: consecutive series of 415 patients from prospective, multicenter, observational study. Cell Transplantation. 2019; 28(6):739-46

Diameter: greater than 2.5 cm ; 5 % of all aneurysms in most series
“Unique and challenging problem in microsurgical or endovascular treatment”

65-100 % mortality  After 2-5 years of follow-up
8-10 % rupture rate

Flow Diverter

Post-procedural complications

Device occlusion and stroke

• Ischemic stroke during the 6 months of follow-up is 3-6 %, with 72,2 % of cases occurring within the first month.
• Of the stenosis (18 %), fortunately none of these cases required further treatment.
• In-stent stenosis was identified in 39 % of PEDs and 5 7% of SILK flow diverters, although the vast majority of patients remained asymptomatic, with high rates of spontaneous resolution.

Occlusion of the branches and perforator

• The incidence of infarct in perforator was 3 %, with the highest number in the posterior circulation.
• In a cohort of 82 patients followed for 10 months, branch occlusion occurred in 15.8 % of cases.

Hemorrhages

• In this case of a 52-year-old female patient with a giant cavernous part of the RICA aneurysm, the flow diverter can be superior to the stent-assisted coil for a complete occlusion
• However, several complications can happen during or after the flow diverter placement; one of them being parent artery stenosis.
• Our patient presented with Gerstmann syndrome which was most likely due to stenosis following procedures, as no abnormalities were found on CT evaluation. Symptoms were completely resolved when the patient received double antiplatelet therapy to prevent occlusion.