Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion

Case report

Full access

Pipeline Embolization Devices (PEDs) have been shown to be effective for intracranial internal carotid artery (ICA) aneurysms, and are now approved by the FDA specifically for this use. Potential pitfalls, however, have not yet been described in the pediatric neurosurgical literature. The authors report on a 10-year-old boy who presented to the Barrow Neurological Institute after progressive visual decline. He had undergone placement of a total of 7 telescoping PEDs at another facility for a large ICA aneurysm. Residual filling of the aneurysm and significant expansion of intraaneurysmal thrombus with chiasmal compression on admission images were causes for concern. The patient underwent a surgical bailout with a superficial temporal artery–middle cerebral artery bypass, with parent artery occlusion. Postoperative vascular imaging was notable for successful occlusion of the parent vessel, with no evidence of filling of the aneurysm.

Reports on the pitfalls of PEDs in the neurosurgical literature are scarce. To the authors' knowledge this represents the first paper describing a successful open surgical bailout for residual aneurysmal filling and expansion of thrombus after placement of a PED.

Abbreviations used in this paper:AP = anteroposterior; ICA = internal carotid artery; MCA = middle cerebral artery; MRA = MR angiography; PED = Pipeline Embolization Device; RA = radial artery; STA = superficial temporal artery.

Abstract

Pipeline Embolization Devices (PEDs) have been shown to be effective for intracranial internal carotid artery (ICA) aneurysms, and are now approved by the FDA specifically for this use. Potential pitfalls, however, have not yet been described in the pediatric neurosurgical literature. The authors report on a 10-year-old boy who presented to the Barrow Neurological Institute after progressive visual decline. He had undergone placement of a total of 7 telescoping PEDs at another facility for a large ICA aneurysm. Residual filling of the aneurysm and significant expansion of intraaneurysmal thrombus with chiasmal compression on admission images were causes for concern. The patient underwent a surgical bailout with a superficial temporal artery–middle cerebral artery bypass, with parent artery occlusion. Postoperative vascular imaging was notable for successful occlusion of the parent vessel, with no evidence of filling of the aneurysm.

Reports on the pitfalls of PEDs in the neurosurgical literature are scarce. To the authors' knowledge this represents the first paper describing a successful open surgical bailout for residual aneurysmal filling and expansion of thrombus after placement of a PED.

The Pipeline Embolization Device (PED) (ev3 Inc.) is now approved by the FDA for use in the US for internal carotid artery (ICA) aneurysms. Despite excellent results in a host of series,1,6,8 there are still some disadvantages and caveats when the device is used for the treatment of difficult intracranial aneurysms.2–5,9,13,14,16 We describe a case in which Pipeline embolization resulted in incomplete treatment and intraaneurysmal thrombus formation, causing mass effect on the optic chiasm and necessitating further treatment.

Case Report

History

We present the case of a 10-year-old boy with a history of Parry-Romberg syndrome, a connective tissue disorder of unknown origin that is characterized by shrinkage of subcutaneous tissue, often in the face. He presented to another hospital with thrombophlebitis over the left eye. At the time of presentation, a giant fusiform left ICA aneurysm with large saccular compartments was diagnosed on MRI studies (Fig. 1), with progressive enlargement after initial imaging. Two months after diagnosis the patient was treated out of state with a PED (Fig. 2). Shortly after this initial endovascular intervention, his vision deteriorated precipitously. Over the course of 1 month, he lost vision in his left eye as well as the temporal hemifield of his right eye (Fig. 3A and B). He was placed on a course of steroids at the other facility, with little improvement in his vision. Magnetic resonance angiography (MRA) studies obtained 2 months later demonstrated continued filling of the aneurysm despite intraaneurysmal thrombus formation, as well as mass effect on the optic chiasm. The patient underwent repeat angiography 5 times, with placement of an additional 6 telescoping PEDs over the course of 4 months. The final construct spanned the cavernous portion of the ICA into the distal left middle cerebral artery (MCA). Follow-up angiograms obtained at 1 month (Fig. 2) and 4 months (Fig. 4) after initial treatment did not show contrast filling of the aneurysm, but at 6 months, MRA studies of the head demonstrated that the aneurysm lumen had progressively accumulated thrombus and was beginning to expand (Fig. 5). Throughout this time, the patient had been maintained on dual-antiplatelet therapy with aspirin and clopidogrel.

Fig. 1.
Fig. 1.

Pretreatment cerebral angiograms obtained in a 10-year-old boy. Anteroposterior (AP) (left) and lateral (right) views are notable for a large, fusiform ICA aneurysm.

Fig. 2.
Fig. 2.

Cerebral AP (A) and lateral (B) angiograms obtained 1 month after PED treatment are notable for absent flow within the aneurysm. Also, lateral (C) and AP (D) scout radiographs of the PED construct were obtained.

Fig. 3.
Fig. 3.

Kinetic visual field testing at 3 months preoperatively in the right eye (A) and left eye (B), and at 6 months postoperatively in the right eye (C) and left eye (D). The results are notable for considerable improvement in visual fields.

Fig. 4.
Fig. 4.

Cerebral AP (A) and lateral (B) angiograms obtained 4 months after PED treatment are notable for absent flow within the aneurysm, but demonstrate progressive MCA stenosis. Scout imaging studies (C and D) of the complex pipeline construct were also obtained.

Fig. 5.
Fig. 5.

Axial (A) and coronal (B) T2-weighted MRI studies obtained 6 months after PED treatment are notable for the large thrombus with chiasmal compression. An MRA time-of-flight image (C) was also obtained.

Examination

Nine months after treatment, the aneurysm continued to show signs of growth. At this point the patient was referred to our institution for evaluation of open surgical options. On the initial visit, the visual deficit in his left eye was fixed, with only intermittent/unreliable light perception. His right eye visual acuity waxed and waned but eventually stabilized to a fixed temporal field cut (Fig. 3). He had otherwise unremarkable examination results, with intact speech, and cognitive/motor function appropriate for his age. An initial diagnostic angiogram performed at our center showed continued filling of the aneurysm with multiple irregularly shaped portions (Fig. 6 left). Bilateral ophthalmic arteries were noted to be filling. The late arterial phase clearly showed the outline of the thrombosed aneurysm (Fig. 6 right). We concluded that despite repeated treatments with the PED the aneurysm continued to fill, resulting in new layers of thrombus that expanded the aneurysm dome and furthered the mass effect on the optic chiasm (Fig. 7).

Fig. 6.
Fig. 6.

The preoperative diagnostic cerebral angiograms obtained 9 months after PED insertion at Barrow Neurological Institute are notable for persistent filling of the ICA aneurysm (left), which is particularly evident in the late arterial phase (right).

Fig. 7.
Fig. 7.

Preoperative plain axial CT scan of the head obtained 9 months after PED insertion at the Barrow Neurological Institute is notable for a large, partially thrombosed ICA aneurysm surrounding the pipeline construct.

Given the risk to vision in his good eye, we recommended treatment with 1) a high-flow bypass from the common carotid artery to the M2 segment of the MCA and 2) clip ligation of the parent vessel, either distal to the aneurysm, proximal to the aneurysm, or both, depending on the findings at the time of surgery. The PED construct had resulted in significant narrowing of the lumen in the distal M1, just proximal to the MCA bifurcation (Fig. 4C). One of our main concerns, in addition to the risk of hypoperfusion of the patient's dominant hemisphere, was the ability to perfuse these lateral lenticulostriate arteries.

Operation

We performed a left orbitopterional craniotomy and exposed the giant aneurysm in the opticocarotid cistern. The sylvian fissure was adherent and friable; therefore we attempted to limit the dissection to what was necessary, given that the operation was in the dominant hemisphere. We easily visualized the PED construct through the parent vessel (Fig. 8). The falciform ligament on both sides of the left optic nerve was opened to decompress and detether the left optic nerve from the skull base. Consideration was given to placing an aneurysm clip between the anterior choroidal artery and the posterior communicating artery. However, this would have excluded the anterior choroidal artery from proximal anterograde flow, leaving only flow across the anterior communicating artery and retrograde through the bypass to perfuse this vessel. We therefore opted not to place a clip distally and proceeded with a superficial temporal artery (STA)–MCA bypass, using both the frontal and parietal branches of the MCA as donor vessels. Cervical carotid artery–MCA bypass with a radial artery (RA) donor was considered but was not performed due to the small size of the RA and its short length, which would probably not withstand future growth of the patient.

Fig. 8.
Fig. 8.

Intraoperative image of the PED visible through the parent vessel. Used with permission from Barrow Neurological Institute.

The first anastomosis was performed to a small (< 1 mm) M3 branch on the temporal side of the sylvian fissure. The second anastomosis was performed using the parietal branch sutured to an RA graft in an end-to-end fashion, followed by an end-to-side anastomosis to an M2/M3 vessel at the level of the sylvian fissure. Indocyanine green angiography demonstrated excellent patency in the larger parietal STA–RA–M2/M3 vessel and sluggish flow in the other vessel of the double-barrel bypass. At this point, we decided to perform partial occlusion of the ICA in the cervical region just distal to the bifurcation. Complete occlusion of the cervical ICA was not performed in case there was insufficient flow from the bypass and across the anterior communicating artery to perfuse his left hemisphere adequately. The decision was made to observe the patient for several days, after which a balloon test occlusion with possible complete occlusion of the cervical ICA would be performed.

Postoperative Course

When the patient woke up, he was at his neurological baseline, without any speech, motor, or cognitive deficit. He underwent MRA on the 1st postoperative day, which showed no filling of his left ICA distal to the common carotid artery bifurcation and no filling of the aneurysm (Fig. 9). The larger vessel of the STA-MCA bypass filled back to the level of the ICA terminus, with flow visualized in his left A1 (Fig. 9C). Because the vessel had already occluded on its own and the patient was neurologically unchanged, the previously planned endovascular test occlusion was unnecessary. He was discharged from the hospital without incident on postoperative Day 3. Six weeks after surgery, he had no further change in his vision and remained at his neurological baseline. Ophthalmological visits with detailed kinetic visual field tests at 2 months and 5 months postoperatively were notable for dramatic improvement in his visual fields (Fig. 3C and D). The ophthalmology report at 5 months stated that the “right temporal visual field defect and paracentral scotoma and left inferonasal island both improving since last field.” Because this young patient had already received exposure to a significant amount of radiation as a result of multiple angiograms, we decided to avoid a formal angiogram for diagnostic purposes at discharge and will perform an MRA study in 1 year.

Fig. 9.
Fig. 9.

Postoperative Day 1 MRA studies (A–C) with progressively higher slices as well as 3D time-of-flight images (D), notable for absent filling of the aneurysm. Panel C shows the patent left STA-MCA bypass. Diffusion-weighted imaging study (E) showing absence of changes.

Discussion

The open vascular treatment of aneurysms that have failed to respond to endoluminal therapies is not a new phenomenon.17 This report represents one of the first cases of open surgical salvage of an aneurysm with a PED construct already in place. Flow diverters, including the Silk flow-diverting stent (Balt Extrusion) and the Pipeline device, are relatively new. As the number of successes accumulates, so have some notable shortcomings.

A recent report of 2 cases has shown that the Pipeline device can result in mural destabilization causing delayed, spontaneous aneurysm growth with possible rupture of the treated aneurysm.5 Others have also reported that thrombosis in an aneurysm treated with flow diversion may not always lead to remodeling but can cause autolysis of the aneurysm wall and delayed rupture; as the authors suggest, the biological behavior of the devices remains to be better understood.7 Although the cause of this phenomenon is unknown, the timing of aneurysm obliteration, if any, could play an important role in the eventual success of treatment; however, this remains to be proven. There is ongoing research in flow dynamics relating to flow diverters, but this represents an understudied field of research.10,11 One such study demonstrated that even reductions in flow velocity do not significantly reduce intraaneurysmal pressure.12

As those who have placed these devices have seen, there is great variability in how quickly aneurysm obliteration occurs. In some cases this can occur almost immediately, whereas others take a much longer period of time. If the obliteration of the aneurysm does not occur fast enough and there is reduction (but not cessation) in flow, there also exists a risk for ingress without adequate egress. This ball-valve mechanism has been shown to result in hemorrhage and death.13 For this reason, some have advocated placement of coils within aneurysms at the same time as PED treatment to aid aneurysm obliteration.14 Thrombus formation within a large aneurysm that has been treated with flow diversion (or even by surgical means) can occur early or late, but as long as the degradation of thrombus is faster than its formation, the aneurysm should not increase in size and result in worsened mass effect.

As is seen in this case, it is also possible to form thrombus within the aneurysm very quickly and cause mass effect. In the aforementioned report from Hampton et al., aneurysm growth resulted in mass effect and edema.5 It is not uncommon for giant aneurysms to cause edema in the surrounding brain and also to have intraluminal nonfilling compartments consisting of thrombus. Such thrombus formation is probably not static but involves ongoing simultaneous deposition and degradation of thrombus material within the aneurysm. In our experience, the natural history of this occurrence is in fact sometimes adversely affected by iatrogenic manipulation, whether surgical ligation or flow diversion. We have previously debulked giant aneurysms internally to reduce the burden of thrombus within the aneurysm and its resultant mass effect. This debulking is sometimes essential, but manipulation of the aneurysm has also exacerbated malignant edema formation in the surrounding brain that can offset the effect of reducing the aneurysm mass. Aneurysm debulking was not performed in this particular patient for fear that it would require further exposure and retraction that might have proven harmful in the dominant hemisphere, especially considering the friability and adherent nature of his sylvian fissure.

Resolution of mass effect and compressive symptoms has been achieved with use of the Pipeline device in difficult aneurysms,15 but in this report the opposite occurred. Rather than alleviating mass effect, previously nonexistent mass effect was induced with flow diverter placement. It is unusual that such a process would occur so quickly after treatment and that significant visual disturbance from chiasm compression rapidly occurred. As the compression persisted, the placement of additional overlapping telescoping devices in an attempt to obliterate the aneurysm and eventually shrink the mass was unsuccessful. This ultimately led to the open surgical bypass and cure of the aneurysm.

Conclusions

We demonstrate here the case of a PED construct that caused mass effect and chiasmopathy in a pediatric patient, presumably due to expanding thrombus within an incompletely obliterated mixed fusiform and saccular giant aneurysm. Treatment for the continued aneurysm filling and mass effect was by occlusion of the parent vessel in the neck with a low-flow bypass to the MCA, resulting in considerable improvement in visual examination results over several months. Although the PED has proven to be successful for many aneurysms, the current report illustrates another cautionary case.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Abla, Albuquerque. Acquisition of data: Abla, Zaidi. Analysis and interpretation of data: Abla, Zaidi. Drafting the article: Abla, Zaidi. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Spetzler. Administrative/technical/material support: all authors. Study supervision: Spetzler, Abla, Zaidi, Crowley, Britz, McDougall.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

References

  • 1

    Becske TKallmes DFSaatci IMcDougall CGSzikora ILanzino G: Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 267:8588682013

  • 2

    Chalouhi NSatti SRTjoumakaris SDumont ASGonzalez LFRosenwasser R: Delayed migration of a pipeline embolization device. Neurosurgery 72:2 Suppl Operativeons229ons2342013

  • 3

    Fargen KMVelat GJLawson MFMocco JHoh BL: Review of reported complications associated with the Pipeline Embolization Device. World Neurosurg 77:4034042012

  • 4

    Fiorella DHsu DWoo HHTarr RWNelson PK: Very late thrombosis of a pipeline embolization device construct: case report. Neurosurgery 67:3 Suppl OperativeonsE313onsE3142010

  • 5

    Hampton TWalsh DTolias CFiorella D: Mural destabilization after aneurysm treatment with a flow-diverting device: a report of two cases. J Neurointerv Surg 3:1671712011

  • 6

    Kan PSiddiqui AHVeznedaroglu ELiebman KMBinning MJDumont TM: Early postmarket results after treatment of intracranial aneurysms with the pipeline embolization device: a U.S. multicenter experience. Neurosurgery 71:108010882012

  • 7

    Kulcsár ZHoudart EBonafé AParker GMillar JGoddard AJ: Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment. AJNR Am J Neuroradiol 32:20252011

  • 8

    Lylyk PMiranda CCeratto RFerrario AScrivano ELuna HR: Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery 64:6326432009

  • 9

    McTaggart RASantarelli JGMarcellus MLSteinberg GKDodd RLDo HM: Delayed retraction of the pipeline embolization device and corking failure: pitfalls of pipeline embolization device placement in the setting of a ruptured aneurysm. Neurosurgery 72:2 Suppl OperativeonsE245onsE2512013

  • 10

    Mut FCebral JR: Effects of flow-diverting device oversizing on hemodynamics alteration in cerebral aneurysms. AJNR Am J Neuroradiol 33:201020162012

  • 11

    Roszelle BNGonzalez LFBabiker MHRyan JAlbuquerque FCFrakes DH: Flow diverter effect on cerebral aneurysm hemodynamics: an in vitro comparison of telescoping stents and the Pipeline. Neuroradiology 55:7517582013

  • 12

    Shobayashi YTateshima SKakizaki RSudo RTanishita KVinuela F: Intra-aneurysmal hemodynamic alterations by a self-expandable intracranial stent and flow diversion stent: high intra-aneurysmal pressure remains regardless of flow velocity reduction. J Neurointerv Surg 5:Suppl 3iii38iii422013

  • 13

    Siddiqui AHAbla AAKan PDumont TMJahshan SBritz GW: Panacea or problem: flow diverters in the treatment of symptomatic large or giant fusiform vertebrobasilar aneurysms. Clinical article. J Neurosurg 116:125812662012

  • 14

    Siddiqui AHKan PAbla AAHopkins LNLevy EI: Complications after treatment with pipeline embolization for giant distal intracranial aneurysms with or without coil embolization. Neurosurgery 71:E509E5132012

  • 15

    Szikora IMarosfoi MSalomváry BBerentei ZGubucz I: Resolution of mass effect and compression symptoms following endoluminal flow diversion for the treatment of intracranial aneurysms. AJNR Am J Neuroradiol 34:9359392013

  • 16

    Velat GJFargen KMLawson MFHoh BLFiorella DMocco J: Delayed intraparenchymal hemorrhage following pipeline embolization device treatment for a giant recanalized ophthalmic aneurysm. J Neurointerv Surg 4:e242012

  • 17

    Waldron JSHalbach VVLawton MT: Microsurgical management of incompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery 64:5 Suppl 23013172009

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Drs. Abla and Zaidi contributed equally to this work.

Address correspondence to: Robert F. Spetzler, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013. email: neuropub@dignityhealth.org.

Please include this information when citing this paper: published online May 16, 2014; DOI: 10.3171/2014.4.PEDS13213.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Pretreatment cerebral angiograms obtained in a 10-year-old boy. Anteroposterior (AP) (left) and lateral (right) views are notable for a large, fusiform ICA aneurysm.

  • View in gallery

    Cerebral AP (A) and lateral (B) angiograms obtained 1 month after PED treatment are notable for absent flow within the aneurysm. Also, lateral (C) and AP (D) scout radiographs of the PED construct were obtained.

  • View in gallery

    Kinetic visual field testing at 3 months preoperatively in the right eye (A) and left eye (B), and at 6 months postoperatively in the right eye (C) and left eye (D). The results are notable for considerable improvement in visual fields.

  • View in gallery

    Cerebral AP (A) and lateral (B) angiograms obtained 4 months after PED treatment are notable for absent flow within the aneurysm, but demonstrate progressive MCA stenosis. Scout imaging studies (C and D) of the complex pipeline construct were also obtained.

  • View in gallery

    Axial (A) and coronal (B) T2-weighted MRI studies obtained 6 months after PED treatment are notable for the large thrombus with chiasmal compression. An MRA time-of-flight image (C) was also obtained.

  • View in gallery

    The preoperative diagnostic cerebral angiograms obtained 9 months after PED insertion at Barrow Neurological Institute are notable for persistent filling of the ICA aneurysm (left), which is particularly evident in the late arterial phase (right).

  • View in gallery

    Preoperative plain axial CT scan of the head obtained 9 months after PED insertion at the Barrow Neurological Institute is notable for a large, partially thrombosed ICA aneurysm surrounding the pipeline construct.

  • View in gallery

    Intraoperative image of the PED visible through the parent vessel. Used with permission from Barrow Neurological Institute.

  • View in gallery

    Postoperative Day 1 MRA studies (A–C) with progressively higher slices as well as 3D time-of-flight images (D), notable for absent filling of the aneurysm. Panel C shows the patent left STA-MCA bypass. Diffusion-weighted imaging study (E) showing absence of changes.

References

1

Becske TKallmes DFSaatci IMcDougall CGSzikora ILanzino G: Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 267:8588682013

2

Chalouhi NSatti SRTjoumakaris SDumont ASGonzalez LFRosenwasser R: Delayed migration of a pipeline embolization device. Neurosurgery 72:2 Suppl Operativeons229ons2342013

3

Fargen KMVelat GJLawson MFMocco JHoh BL: Review of reported complications associated with the Pipeline Embolization Device. World Neurosurg 77:4034042012

4

Fiorella DHsu DWoo HHTarr RWNelson PK: Very late thrombosis of a pipeline embolization device construct: case report. Neurosurgery 67:3 Suppl OperativeonsE313onsE3142010

5

Hampton TWalsh DTolias CFiorella D: Mural destabilization after aneurysm treatment with a flow-diverting device: a report of two cases. J Neurointerv Surg 3:1671712011

6

Kan PSiddiqui AHVeznedaroglu ELiebman KMBinning MJDumont TM: Early postmarket results after treatment of intracranial aneurysms with the pipeline embolization device: a U.S. multicenter experience. Neurosurgery 71:108010882012

7

Kulcsár ZHoudart EBonafé AParker GMillar JGoddard AJ: Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment. AJNR Am J Neuroradiol 32:20252011

8

Lylyk PMiranda CCeratto RFerrario AScrivano ELuna HR: Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery 64:6326432009

9

McTaggart RASantarelli JGMarcellus MLSteinberg GKDodd RLDo HM: Delayed retraction of the pipeline embolization device and corking failure: pitfalls of pipeline embolization device placement in the setting of a ruptured aneurysm. Neurosurgery 72:2 Suppl OperativeonsE245onsE2512013

10

Mut FCebral JR: Effects of flow-diverting device oversizing on hemodynamics alteration in cerebral aneurysms. AJNR Am J Neuroradiol 33:201020162012

11

Roszelle BNGonzalez LFBabiker MHRyan JAlbuquerque FCFrakes DH: Flow diverter effect on cerebral aneurysm hemodynamics: an in vitro comparison of telescoping stents and the Pipeline. Neuroradiology 55:7517582013

12

Shobayashi YTateshima SKakizaki RSudo RTanishita KVinuela F: Intra-aneurysmal hemodynamic alterations by a self-expandable intracranial stent and flow diversion stent: high intra-aneurysmal pressure remains regardless of flow velocity reduction. J Neurointerv Surg 5:Suppl 3iii38iii422013

13

Siddiqui AHAbla AAKan PDumont TMJahshan SBritz GW: Panacea or problem: flow diverters in the treatment of symptomatic large or giant fusiform vertebrobasilar aneurysms. Clinical article. J Neurosurg 116:125812662012

14

Siddiqui AHKan PAbla AAHopkins LNLevy EI: Complications after treatment with pipeline embolization for giant distal intracranial aneurysms with or without coil embolization. Neurosurgery 71:E509E5132012

15

Szikora IMarosfoi MSalomváry BBerentei ZGubucz I: Resolution of mass effect and compression symptoms following endoluminal flow diversion for the treatment of intracranial aneurysms. AJNR Am J Neuroradiol 34:9359392013

16

Velat GJFargen KMLawson MFHoh BLFiorella DMocco J: Delayed intraparenchymal hemorrhage following pipeline embolization device treatment for a giant recanalized ophthalmic aneurysm. J Neurointerv Surg 4:e242012

17

Waldron JSHalbach VVLawton MT: Microsurgical management of incompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery 64:5 Suppl 23013172009

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 87 87 35
PDF Downloads 143 143 18
EPUB Downloads 0 0 0

PubMed

Google Scholar