Sequential Coiling-Assisted Deployment of Flow Diverter for Treatment of Fusiform Middle Cerebral Artery Aneurysms

BACKGROUND AND IMPORTANCE: Fusiform intracranial aneurysms remain challenging lesions to treat. These aneurysms have historically required bypass procedures or clip remodeling constructs for cure. Recently, endovascular specialists have reported experience with flow diversion for complex fusiform aneurysms of the vertebrobasilar system, with mixed results. Vascular anatomy for anterior circulation fusiform aneurysms may make these lesions more amenable to flow diversion and embolization procedures; however, published experience with these techniques is lacking. In this report, we describe a sequential coiling-assisted deployment of flow diverter for the treatment of fusiform middle cerebral artery (MCA-M1) aneurysms in 2 cases, 1 presenting acutely with subarachnoid hemorrhage and another with progressive aneurysm enlargement. CLINICAL PRESENTATION: Two patients, a 36-yr-old male presenting with subarachnoid hemorrhage and a 60-yr-old female presenting with aneurysm enlargement were treated for fusiform aneurysms of the M1 segment of the MCA using a sequential, partial deployment of coils and flow diverter through 2 microcatheters to facilitate mutual mechanical support for both coil and flow diverter (Pipeline Embolization Device; Medtronic Inc, Dublin, Ireland). Both patients achieved favorable outcomes and follow-up angiography demonstrated complete vessel reconstruction in both cases. CONCLUSION: The treatment of complex, fusiform, large vessel aneurysms remains challenging. As experience with new endovascular technologies and techniques grows, these lesions may be treated safely with interventional methods. The technique of partial flow diverter deployment and stabilization with coils with sequential delivery of both devices using dual microcatheter was both safe and effective.