Background Use of flow-diversion technology in the treatment of incidental and recanalized posterior communicating artery (PComA) aneurysms. Methods Patients treated with the Pipeline embolization device (PED) for PComA aneurysms were identified and included in our retrospective analysis. We evaluated aneurysm characteristics, modified Rankin Scale score (mRS) on admission, angiography follow-up, and patient clinical outcome at discharge, at three to nine months, and at 12-18 months. Results We included 56 patients with a mean age of 56 years. Median mRS on admission was 0. All aneurysms involved the PComA and were either new findings or found to have shown recanalization at angiography follow-up from previous coil embolization or surgical clipping. Intraprocedural device foreshortening was observed in one case requiring additional placement of a self-expanding stent. One intraprocedural aneurysm rupture occurred because of a broken distal wire. This patient had an mRS of 4 after the procedure. Three- to nine-month and 12- to 18-month follow-up angiography showed near complete or complete aneurysm occlusion in most cases. Minimal to mild intimal hyperplasia was seen in five cases at three to nine months. PComA patency over time showed 29 of 46 initially patent vessels still patent at six months. Thirteen and seven PComAs showed progressive decrease in flow at three to nine months and 12-18 months, respectively. Median mRS remained 0 for all patients at three- to nine-month and 12- to 18-month follow-up. Conclusions Our preliminary results show that flow-diversion technology is an effective and safe treatment option. Larger studies with long-term follow-up are needed to validate our promising results.

A 54-year-old male with metastatic melanoma, including a presumed brain metastasis underwent elective surgery when there was sudden onset of extensive bleeding upon resection. An emergent cerebral angiogram revealed a fusiform left posterior cerebral artery aneurysm. Malignant melanoma commonly metastasizes to the brain and has shown to assume a wide variety of appearances with involvement of almost any intracranial structures. The unexpected intraoperative finding required immediate action and strategic rethinking. The patient successfully underwent vessel sacrifice by means of coil embolization.

Background Flow diverter (FD) malapposition is associated with stroke-related complications. We document the use of self-expanding nitinol stents to remove/reduce the ledge of a FD deployed for aneurysm treatment. Methods We identified five patients who were treated with the Pipeline embolization device (PED) in conjunction with a Neuroform EZ stent for inadequate wall apposition of the ends of the FD at our institution between May 2014 and July 2015. Among other parameters, angiographic results, cone-beam computed tomography assessment of wall apposition and patient clinical outcome were evaluated. Results Incomplete device end apposition was seen in three cases, and precarious positioning of the distal end of the PED over the aneurysm neck was seen in two cases. In all five cases, successful treatment with good wall apposition and proper pinning of the PED distal edge was achieved using an additional Neuroform EZ stent. Appropriate aneurysm neck coverage and flow stagnation was seen in all cases. The combination of high radial outward force and open-cell design permits the Neuroform EZ stent to jail the malappositioned edges of the FD while maintaining good vessel-wall apposition itself and prevent migration of the PED. Short-term follow-up angiography showed device patency and complete aneurysm obliteration in all cases. Conclusions Preliminary results of this small case series suggest that the Neuroform EZ stent allows for effective treatment of FD malapposition in selected patients amenable for this endovascular approach. Long-term and larger cohort studies are needed to validate these results.