Technical nuances of flow-diverting stent-assisted coiling of a ruptured carotid wall aneurysm

The management of ruptured, large and giant wide-necked aneurysms of the anterior circulation is challenging. Treatment options include balloon-assisted coiling versus flow-diverter-assisted coiling. In this technical video, we demonstrate a case of a right-sided paraclinoid aneurysm in a young man who presented with post-coital sudden-onset headache. The computed tomography scan showed a Fisher grade IV subarachnoid hemorrhage. An external ventricular drain was placed, and the patient was intubated for prompt treatment. Balloon-assisted coiling of the aneurysm was attempted but abandoned because the balloon failed to provide adequate coverage of the aneurysm neck. A loading dose of aspirin and ticagrelor (Brilinta, Astra Zeneca, Cambridge, United Kingdom) was administered, and Pipeline embolization device (Medtronic, Dublin, Ireland)-assisted coiling was then performed for adequate occlusion of the aneurysm sac. The 6-month follow-up angiogram showed complete obliteration of the aneurysm. The technical video succinctly demonstrates the technical nuances of the procedure.