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. 2022 Jan 6;12:801470. doi: 10.3389/fneur.2021.801470

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Copyright © 2022 Schob, Brill, Siebert, Sponza, Schüngel, Wohlgemuth, Götz, Mucha, Gopinathan, Scheer, Prell, Bohner, Gavrilovic and Skalej.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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Indirect flow diversion for treatment of an incidental broad-based aneurysm of the anterior communicating artery in a 44-year-old patient. The left A1 segment is dominant; the right A1 segment is hypoplastic (0.7 mm) but contributes significantly to the supply of the ipsilateral anterior cerebral artery territory. The aneurysm (7 × 7 mm fundus, 3.3-mm neck) arises from the middle of the anterior communicating artery (2 mm in diameter). The aneurysm is 2.4 mm distant to the origin of the anterior communicating artery at the A1–A2 junction of the left-hand side. Upper row (A–C): Implantation of a Silk Vista Baby flow-diverting stent into the left A1–A2 segment. (A) Initial angiogram of the left-hand side internal carotid artery in posterior-anterior projection prior to implantation. Note the strong crossflow to the contralateral middle cerebral artery via the anterior communicating artery. (B) Working projection, prior implantation. The white lines indicate the intended proximal and distal landing zones. The upper left image shows the correspondingly implanted flow diverter. (C) Control injection after implantation. The aneurysm dome is already less opacified, indicating a good therapeutic effect. Middle row: (D–F) result, 10-min post implantation. (D) Despite a forceful injection, there is no more crossflow to the contralateral vessels. (E) The anterior communicating artery, including the aneurysm, is no longer opacified. The white lines indicate the proximal and distal endings of the implanted device. (F) Injection of the contralateral side: the aneurysm is slightly opacified from the right-hand side A1 segment. Inferior row (G–I): Follow-up angiograms 3 months after treatment. (G) Angiogram of the left-hand side internal carotid artery in posterior-anterior projection comparable to (A). The aneurysm is occluded, no crossflow to the contralateral side. (H) Magnified image in a slightly oblique projection to visualize the A1–A2 junction. Mild-moderate neointimal hyperplasia at the proximal landing zone. The white lines indicate the proximal and distal endings of the implanted device. (I) Angiogram of the right-hand side internal carotid artery in a projection matching. (F) The aneurysm is no longer opacified via the contralateral A1.