“Slow-deconstructive” approach in a patient with acute stroke and fusiform MCA aneurysm

Patient situation

• This 45-year-old patient presented with acute mild aphasia and facial palsy
• MRA revealed an embolic stroke in the left inferior precentral gyrus, related to a non-ruptured fusiform MCA aneurysm in the Sylvian fissure
• Her stroke-related neurological symptoms completely resolved under conservative treatment

Treatment chosen

DWI

TOF MRA

i.v. DCT

• The left MCA fusiform aneurysm measured 13 mm; however, the carrier vessel diameter was below 1 mm
• Treatment was initiated 6 months after the embolic event
• Indirect flow diversion of the origin of the carrier vessel under DAPT with aspirin and prasugrel was chosen

• A Pipeline Vantage  2.5 x 10 mm Flow Diverter was deployed into the parietal M2-branch from which the carrier vessel arose.
• The patient stayed under DAPT with ASS 100 mg/d and Prasugrel 10 mg/d for 3 months and prasugrel monotherapy for another 3 months

Follow-up (6 months)

Pre

Post (6 months)

• MRA and i.v. DCT at 6 months confirming occlusion of the aneurysm and subtotal involution of the carrier branch. The patient had no symptoms and no new infarcts after treatment 

Results

• Indirect flow diversion can be an option in peripheral cerebral aneurysms with low carrier vessel diameter
• In this case, we used an aggressive antiplatelet regimen in order to avoid any further embolic events under flow diversion
• No procedure-related complications occurred; there was no further embolic event after treatment, also confirmed by MRI
• In the case described, the “slow-deconstructive” approach might be less risky than an endoluminal reconstruction of the diseased vessel

Supported by Medtronic