Flow Diversion of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device

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Introduction: Traumatic middle cerebral artery (MCA) pseudoaneurysms are rare cerebrovascular lesions which can be challenging to safely treat when they are localized to proximal segments of the vessel which cannot be sacrificed. multiple endovascular and surgical treatment options have been described with varying degrees of efficacy.

Methods: We Describe The endovascular management of traumatic internal carotid artery (ICA) and MCA M1 superior division pseudoaneurysms with flow diversion.

Results: A 19-year-old male sustained a gunshot wound to the head. initial computed tomography angiogram showed only mild vasospasm of the left ICA and MCA. Catheter digital subtraction angiography (DSA) on post-injury day (PID) 7 showed a 1.4 mm × 2.0 mm pseudoaneurysm arising from the ophthalmic segment of the left ICA and a second 3.6 mm × 3.2 mm arising from the left MCA superior division. on PID 9, we performed coil embolization of the left MCA pseudoaneurysm. follow-up DSA 2-weeks after the coiling procedure showed recurrence of the left MCA pseudoaneurysm, with unchanged appearance of the left ICA pseudoaneurysm. At this time, we performed flow diversion of both the left ICA and recurrent MCA pseudoaneurysms using two pipeline flex embolization devices (Medtronic Neurovascular, Irvine, CA, United States). The patient was maintained on a dual antiplatelet regimen of (aspirin, 325 mg daily and Brilinta, 90 mg twice a day). Postembolization DSA 6 months after the flow diversion procedure showed complete obliteration of both pseudoaneurysms with preserved patency of left the ICA and MCA. The patient was neurologically intact at follow-up, without evidence of ischemic symptoms.

Conclusion: Flow diversion is an efficacious treatment for traumatic MCA pseudoaneurysms, with a favorable risk to benefit profile in appropriately selected cases. the use of dual antiplatelet therapy necessary to minimize the risk of thromboembolic complications after flow diversion must be balanced against the risk of hemorrhagic complications in the setting of recent trauma.