Delayed Occlusion of the Anterior Choroidal Artery Following Flow Diverter Stent Deployment for Unruptured Aneurysm: A Case Report and Literature Review

Abstract

Flow diverter stent has been a promising device for intracranial aneurysm treatment. For treating aneurysms located in the anterior circulation, critical branches may be covered by flow diverter stent. The occlusion incidence of these branches has been reported, and even if branch vessel occlusions occur, associated neurological deficits are extremely rare. We present a 55-year-old woman who had a large saccular aneurysm at the right internal carotid artery (ICA). A developed fetal-type posterior communicating artery (PCOM) originated from the sac. We administered flow diverter stent deployment with coil insertion following surgical anastomosis of the superficial temporal artery to the posterior cerebral artery (STA-PCA) with ligation of the origin of the PCOM. On the seventh morning following the intervention, ischemic complication developed due to anterior choroidal artery occlusion jailed by the flow diverter stent. The occlusion of anterior choroidal artery covered by flow diverter stent is extremely rare. However, if the branch arises from the aneurysm sac, occlusion can transpire and induce serious complication. The most probable cause of occlusion in this case was that the orifice was jailed apart from the stent strut because the branch originated from the sac rather than the neck. Furthermore, the progression rate of intra-aneurysm thrombus formation is also an important factor affecting the side branch occlusion.

Paraclinoid internal carotid artery aneurysm with delayed stent occlusion after deployment of a flow diverter stent involving the orifice of the anterior cerebral artery: illustrative case

“… 14–16 The AChoA is occluded in only approximately 0% to 4% of cases, and symptomatic occlusion is extremely rare. 13 , 14 , 17 , 18 In our case, despite in-stent occlusion, the AChoA territory was preserved by collateral flow from the posterior choroidal artery and did not become symptomatic. However, symptomatic occlusion can occur in situations in which the AChoA is branching from the dome of the aneurysm.…”

“…However, symptomatic occlusion can occur in situations in which the AChoA is branching from the dome of the aneurysm. 13 When the orifice of the ACA is included in the FD, a high rate of occlusion of antegrade flow has been reported in the ACA (14%–64%), but this occlusion is not symptomatic because of sufficient contralateral blood flow through the AComA. However, when in-stent occlusion occurs, as in the present case, the perfusion territory of the MCA is extensively ischemic, resulting in an extremely dangerous situation.…”

A vertebrobasilar junction aneurysm successfully treated with a combination of surgical clipping and flow diverter placement based on the results of computational fluid dynamics analysis: illustrative case

“…[14][15][16][17] Consequently, strategies involving the occlusion of inflow or outflow vessels prior to FD placement have been reported; however, in cases in which the VA was sacrificed using coils, brainstem infarctions occurred in two of six cases. [18][19][20] In our case, surgical trapping was performed to occlude the left VA while visually confirming a small perforator arising from the left VA and finally preserving it, resulting in no complications and a favorable outcome. In the surgical trapping of the VA, direct surgery is more ideal than endovascular internal trapping for placing clips while observing nearby branching arteries and thus reducing postoperative infarction risks despite the risk of cranial nerve palsy.…”