No abstract

A 64-year-old male patient was brought to the referring hospital after an acute onset of a paresis of his right arm and a motoric aphasia without headache. Assuming an ischemic stroke, an MRI/MRA was performed, followed by a CT examination. These revealed a massive subarachnoid hemorrhage (SAH) from a mid-sized, wide-necked aneurysm at the origin of the left superior cerebellar artery (SCA). The aneurysm and in particular the rupture site were occluded with a Medina device (Medtronic) and conventional coils. The patient recovered well from the SAH. DSA 3 months after this treatment showed some coil compaction adjacent to the aneurysm neck. A second follow-up DSA 6 months after the initial treatment showed an increase of the aneurysm reperfusion, which was considered to be a sign of unstable aneurysm occlusion. To reduce the hemodynamic impact on the aneurysm remnant and to allow for a remodeling of the left SCA, a p64 (phenox) flow diverter was implanted from the left posterior cerebral artery (PCA) to the distal basilar artery (BA). This procedure was again well tolerated. A follow-up DSA examination 9.5 months after the first and 3 months after the second treatment showed decreased aneurysm reperfusion and an incomplete remodeling of the proximal segment of the left SCA. The management of wide-necked, ruptured aneurysms using Medina and secondary extrasaccular flow diversion is the main topic of this chapter.