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The pipeline embolization device (PED) is a well recognized treatment for intracranial aneurysms. However, uncertainty remains regarding its effects on flow alteration, which is particularly highlighted by persistently perfused aneurysmal remnants and non-regressing, non-perfused aneurysmal masses. Here we present a 68-year-old woman with an incidental giant fusiform right paraophthalmic aneurysm electively treated with a PED. After lowering her antiplatelet therapy to promote aneurysm thrombosis, she was found to have a progressively enlarging perfused aneurysmal remnant. Angiography revealed PED occlusion, but curiously the development of a peri-construct collateral channel which feeds the aneurysmal remnant, and gives rise to distal branches and contributes to middle cerebral artery flow. The large 'thrombosed' aneurysmal mass showed tiny internal vessels on cone beam CT angiography as well as florid enhancement on MRI, further confirming that apparently thrombosed remnants are biologically active and may be remodeled depending on flow demand., (2016 BMJ Publishing Group Ltd.)

More than half a decade of experience and follow-up has now been accumulated with regard to flow diversion as a treatment for intracranial aneurysms; however, many uncertainties, such as the nature of aneurysmal remnants and the meaning of non-regressed, non-perfused aneurysmal masses, are still unknown. Here we discuss a 22-year-old man who presented with a grade 1 subarachnoid hemorrhage secondary to a dissecting right anterior cerebral artery aneurysm who was subsequently treated with a Pipeline Embolization Device construct. After ceasing dual antiplatelet therapy himself, he was found on MRI to have an area of increased aneurysmal remnant reperfusion. This was found to connect to multiple channels which reconstituted flow within the distal construct on angiography. The central area of construct thrombosis could not be visualized on MRI. The finding suggests that non-opacified aneurysmal remnants that have not regressed are biologically active and raises concerns regarding using MRI for long term follow-up., (2015 BMJ Publishing Group Ltd.)

Intracranial aneurysms in polyarteritis nodosa (PAN) are exceedingly rare lesions with unpredictable behavior that pose real challenges to microsurgical and endovascular interventions owing to their inflammatory nature. We introduce a safe and effective alternative for treating these aneurysms using Pipeline embolization devices (PEDs). A 20-year-old man presented with diplopia, headaches, chronic abdominal pain, and weight loss. Diagnostic evaluations confirmed PAN, including bilateral giant cavernous carotid aneurysms. Cyclophosphamide and steroids achieved significant and sustained clinical improvement, with a decision to follow the aneurysms serially. Seven years later the left unruptured aneurysm enlarged, causing a sudden severe headache and a cavernous sinus syndrome. Treatment of the symptomatic aneurysm was pursued using flow diversion (PED) and the internal carotid artery was successfully reconstructed with a total of four overlapping PEDs. At 6 months follow-up, complete exclusion of the aneurysm was demonstrated, with symptomatic recovery. This is the first description of using a flow-diverting technique in an inflammatory vasculitis. In this case, PEDs not only attained a definitive closure of the aneurysm but also reconstructed the damaged and fragile arterial segment affected with vasculitis., (2015 BMJ Publishing Group Ltd.)

Crossing the neck of large complex intracranial aneurysms for the purposes of stent deployment can be challenging using standard over the wire techniques. We describe a novel yet simple technique for straightening out the loop formed within a large intracranial aneurysm, which is often required in order to cross the aneurysm neck into the distal branch. Both the microcatheter and microwire are initially introduced into the distal vasculature, followed by withdrawal of the microwire to a point parallel to the distal exiting branch. The microcatheter and microwire are then gently withdrawn and a series of maneuvers to gradually reduce the loop is performed, obviating the need for distal purchase in the form of a stent, balloon, or coil, which have previously been described to maintain distal purchase., (2015 BMJ Publishing Group Ltd.)