Kumar Jeyan Sathia, Dabhi Nisha, Raper Daniel M S, Capek Stepan, Crowley R Webster, Kalani M Yashar, Kellogg Ryan T, Park Min S
1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia.
2Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas.
J Neurosurg Case Lessons. 2023 Sep 18;6(12). doi: 10.3171/CASE23369.
Flow diversion, specifically with the Pipeline embolization device (PED), represents a paradigm shift in the treatment of intracranial aneurysms. Several studies have demonstrated its efficacy and at times superiority to conventional treatment modalities for aneurysms with a fusiform morphology, giant size, or wide neck. However, there may be a nonsignificant risk of recurrence after flow diversion of these historically difficult-to-treat aneurysms, relative to aneurysms with a more favorable morphology and size (i.e., saccular, narrow necked). To date, only three papers in the literature have demonstrated the recurrence of a completely occluded aneurysm on follow-up.
The authors describe a patient with a giant middle cerebral artery fusiform aneurysm treated with multiple telescoping PEDs. On the 3-month follow-up angiogram, there was complete occlusion of the aneurysm. The patient was lost to follow-up and presented 4 years later with a recurrence of the aneurysm between PED segments, requiring retreatment. The patient represented 3 years posttreatment with the need for repeat treatment of the fusiform aneurysm due to separation of the existing PEDs along with stent reconstruction. At the 20-month follow-up after the third treatment, the initial aneurysm target was found to be occluded.
This case illustrates the need for long-term follow-up, specifically for patients with giant wide-necked or fusiform aneurysms treated with overlapping PEDs.
血流导向，特别是使用Pipeline栓塞装置（PED），代表了颅内动脉瘤治疗的范式转变。多项研究已证明其疗效，并且对于具有梭形形态、巨大尺寸或宽颈的动脉瘤，有时优于传统治疗方式。然而，相对于形态和尺寸更有利的动脉瘤（即囊状、窄颈），这些历来难以治疗的动脉瘤在血流导向后可能存在不显著的复发风险。迄今为止，文献中仅有三篇论文证明了随访时完全闭塞的动脉瘤出现复发。
作者描述了一名患有大脑中动脉巨大梭形动脉瘤的患者，接受了多个串联的PED治疗。在3个月的随访血管造影中，动脉瘤完全闭塞。该患者失访，4年后因PED节段间动脉瘤复发而再次就诊，需要再次治疗。该患者在治疗3年后，由于现有PED分离并需要进行支架重建，梭形动脉瘤需要再次治疗。在第三次治疗后的20个月随访中，最初的动脉瘤靶点被发现已闭塞。
该病例表明需要进行长期随访，特别是对于接受重叠PED治疗的巨大宽颈或梭形动脉瘤患者。
