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Large, wide-necked basilar apex aneurysms are difficult to treat. Microsurgical clipping can result in neurologic morbidity and mortality. Endovascular treatment often leaves remnants that need retreatment and/or stent placement with dual antiplatelet therapy. The Woven EndoBridge (WEB) is an intrasaccular flow disruption device that can be used without dual antiplatelet therapy. However, the WEB cannot typically be used in large or giant aneurysms > 10 mm because the largest diameter device is the 11 × 9.6 mm single layer sphere (SLS). We present a case in which we use a PulseRider aneurysm neck reconstruction device in the basilar artery to assist in WEB deployment within a 22 mm basilar apex aneurysm with 14 mm neck, thereby permitting aspirin monotherapy postoperatively.

Checkpoint proteins reduce immune-mediated responses to promote self-tolerance and prevent autoimmunity. Programmed cell death protein 1 (PD-1) is a checkpoint receptor protein expressed on leukocytes that inactivates T cell–mediated immunity when bound to ligand PD-L1. Certain tumors can escape immune-mediated destruction by expressing high concentrations of PD-L1, evading host surveillance.1 PD-1 pathway inhibitors effectively treat multiple malignancies including melanoma, non-small cell lung cancer, and squamous cell carcinoma.2 However, there is increasing recognition of immune-related adverse events (irAE) associated with checkpoint inhibitor therapy due to dysregulated immune system activation.1 We report immune-mediated cerebellitis following pembrolizumab.