Fig. 1.

a Digital subtraction angiogram (DSA) shows a large wide-necked unruptured paraclinoid right internal carotid artery (ICA) aneurysm. b Unsubtracted lateral view immediately after Pipeline embolization device (PED) ‣1 shows contrast stagnation in aneurysm and apposition of PED to parent ICA. c DSA of right ICA in lateral view immediately after PED ‣1 shows patent anterograde flow and no evidence of carotid-cavernous fistula (CCF). Subsequent DSA of the right ICA in frontal (d) and lateral (e) views shows decreased anterograde flow and development of CCF with retrograde flow anteriorly through the superior ophthalmic vein (arrows), inferiorly to the pterygoid plexus (arrowheads) and clival plexus (open arrows). After deployment of four additional PEDs, DSA of the right ICA in frontal (f) and lateral (g) views shows improved anterograde flow and decreased filling of CCF. h 12-month follow-up DSA of the right ICA in lateral view shows vessel reconstruction with resolution of CCF.