Internal Carotid Artery Aneurysm: Multiple Internal Carotid Artery Aneurysms in a Patient Presenting with Subarachnoid Hemorrhage; Treatment with Flow Diverter Stents

  • José E. CohenEmail author
  • Asaf Honig
  • Gustavo Rajz
Living reference work entry


Up to 30% of patients presenting with acute aneurysmal hemorrhage are found to have multiple aneurysms. As the determination of the source of the bleeding may not be straightforward in the cases of multiple aneurysms, the simultaneous treatment of all aneurysms is often considered. We present the case of a 41-year-old woman with an unremarkable medical history apart from chronic headaches, who presented with a left-sided basal subarachnoid hemorrhage (SAH; Hunt and Hess II, Fisher grade III). Neuroradiological examinations, including CT and CT angiography (CTA), revealed a midsized carotid ophthalmic aneurysm at the left internal carotid artery (ICA). Angiography confirmed the diagnosis of the ophthalmic aneurysm and depicted two other small aneurysms on the posterior communicating (PcomA) and anterior choroidal (AchoA) arteries. An external ventricular drain was inserted and the patient was given loading doses of aspirin and prasugrel. All three aneurysm ostia were completely covered by the implantation of two telescoping flow diverter stents in a single uneventful procedure. The ventriculostomy was removed after day 7 and the patient was discharged home after 12 days. Follow-up head CT at days 5 and 10 showed no hydrocephalus. Follow-up angiography at 3 months confirmed occlusion of all three left ICA aneurysms. Prasugrel was discontinued at month 4 and aspirin was continued indefinitely. The safety and effectiveness of flow diverter stent implantation in the management of multiple carotid aneurysms, including the less-explored situation of multiple aneurysms presenting with SAH, is the main topic of this chapter.


Internal carotid artery Flow diverter stent Multiple aneurysms Subarachnoid hemorrhage 


  1. Amenta PS, Dalyai RT, Kung D, Toporowski A, Chandela S, Hasan D, Gonzalez LF, Dumont AS, Tjoumakaris SI, Rosenwasser RH, Maltenfort MG, Jabbour PM. Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65 patients. Neurosurgery. 2012;70(6):1415–29; discussion 1429. Scholar
  2. Backes D, Vergouwen MD, Velthuis BK, van der Schaaf IC, Bor AS, Algra A, Rinkel GJ. Difference in aneurysm characteristics between ruptured and unruptured aneurysms in patients with multiple intracranial aneurysms. Stroke. 2014;45(5):1299–303. Scholar
  3. Bodily KD, Cloft HJ, Lanzino G, Fiorella DJ, White PM, Kallmes DF. Stent-assisted coiling in acutely ruptured intracranial aneurysms: a qualitative, systematic review of the literature. AJNR Am J Neuroradiol. 2011;32(7):1232–6. Scholar
  4. Cai K, Ji Q, Cao M, Shen L, Xu T, Zhang Y. Association of different stenting procedures with symptomatic thromboembolic complications in stent-assisted coiling of ruptured wide-necked intracranial aneurysms. World Neurosurg. 2017;104:824–30. Scholar
  5. Chalouhi N, Jabbour P, Singhal S, Drueding R, Starke RM, Dalyai RT, Tjoumakaris S, Gonzalez LF, Dumont AS, Rosenwasser R, Randazzo CG. Stent-assisted coiling of intracranial aneurysms: predictors of complications, recanalization, and outcome in 508 cases. Stroke. 2013;44(5):1348–53. Scholar
  6. Chung J, Lim YC, Suh SH, Shim YS, Kim YB, Joo JY, Kim BS, Shin YS. Stent-assisted coil embolization of ruptured wide-necked aneurysms in the acute period: incidence of and risk factors for periprocedural complications. J Neurosurg. 2014;121(1):4–11. Scholar
  7. Cohen JE, Gomori JM, Leker RR, Spektor S, Abu El Hassan H, Itshayek E. Stent and flow diverter assisted treatment of acutely ruptured brain aneurysms. J Neurointerv Surg. 2018;10(9):851–8. Scholar
  8. Greving JP, Wermer MJ, Brown RD Jr, Morita A, Juvela S, Yonekura M, Ishibashi T, Torner JC, Nakayama T, Rinkel GJ, Algra A. Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. Lancet Neurol. 2014;13(1):59–66. Scholar
  9. Juvela S. Risk factors for multiple intracranial aneurysms. Stroke. 2000;31(2):392–7.CrossRefGoogle Scholar
  10. Lessne ML, Shah P, Alexander MJ, Barnhart HX, Powers CJ, Golshani K, Ferrell A, Enterline D, Zomorodi A, Smith T, Britz GW. Thromboembolic complications after Neuroform stent-assisted treatment of cerebral aneurysms: the Duke Cerebrovascular Center experience in 235 patients with 274 stents. Neurosurgery. 2011;69(2):369–75. Scholar
  11. Mizoi K, Suzuki J, Yoshimoto T. Surgical treatment of multiple aneurysms. Review of experience with 372 cases. Acta Neurochir. 1989;96(1–2):8–14.CrossRefGoogle Scholar
  12. Nehls DG, Flom RA, Carter LP, Spetzler RF. Multiple intracranial aneurysms: determining the site of rupture. J Neurosurg. 1985;63(3):342–8.CrossRefGoogle Scholar
  13. Omodaka S, Endo H, Niizuma K, Fujimura M, Endo T, Sato K, Sugiyama SI, Inoue T, Tominaga T. Circumferential wall enhancement on magnetic resonance imaging is useful to identify rupture site in patients with multiple cerebral aneurysms. Neurosurgery. 2018;82(5):638–44. Scholar
  14. Rinne J, Hernesniemi J, Puranen M, Saari T. Multiple intracranial aneurysms in a defined population: prospective angiographic and clinical study. Neurosurgery. 1994;35(5):803–8.CrossRefGoogle Scholar
  15. Tähtinen OI, Vanninen RL, Manninen HI, Rautio R, Haapanen A, Niskakangas T, Rinne J, Keski-Nisula L. Wide-necked intracranial aneurysms: treatment with stent-assisted coil embolization during acute (<72 hours) subarachnoid hemorrhage – experience in 61 consecutive patients. Radiology. 2009;253(1):199–208. Scholar
  16. Valen-Sendstad K, Steinman DA. Mind the gap: impact of computational fluid dynamics solution strategy on prediction of intracranial aneurysm hemodynamics and rupture status indicators. AJNR Am J Neuroradiol. 2014;35(3):536–43. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryHadassah-Hebrew University Medical CenterJerusalemIsrael
  2. 2.Department of NeurosurgeryShaare Zedek Medical CenterJerusalemIsrael

Personalised recommendations