Introduction: Flow diversion has emerged as a promising alternative for the treatment of intracranial aneurysms. Relatively new to the market, the potential complications of these devices are still being characterized. We report a case of acute distal migration of a flow diverting stent immediately after treatment.
Results: We report a 24-year old female who presented electively for flow diversion of a left paraclinoid aneurysm. She had been started on dual anti-platelet therapy 7 days before treatment. Her P2Y12 was 194 PRU on the day of treatment. Intra-operatively, she was found to have 4.1 x 5.0 x 4.8 mm aneurysm in the vicinity of the superior hypophyseal artery, and a flow diverting stent (Pipeline Embolization Device) was placed without intra-operative complication under therapeutic heparinization. Immediate post-placement angiography revealed stagnation within the aneurysm dome with no evidence of impaired flow. Upon emergence from general anesthesia, the patient was initially moving all extremities symmetrically. Shortly thereafter, she developed acute right hemiparesis and a right facial droop while still on the operative table. Angiography was emergently repeated, which revealed complete thrombosis of the stent and proximal MCA as well as migration of the flow diversion device to the supraclinoid ICA. The patient received intra-arterial tissue plasminogen activator and aspiration of the thrombus. Despite TICI 3 revascularization, the patient unfortunately suffered a dominant left MCA infarct.
Conclusions: While flow diversion continues to play an expanding role in the treatment of intracranial aneurysms, many potential complications remain unknown. Flow diverter migration has been previously reported in a delayed chronic fashion, believed to be secondary to chronic in-stent thrombus formation. Given the complete occlusive thrombus in this case, this is the likely etiology underlying the device migration. We report the first case of an acute distal migration of a flow diversion device immediately after treatment.
Patient Care: Through better understanding of potential complications associated with flow diversion, pre-operative patient-centered discussion will be more informed, and surgeons can be better equipped to respond to complications if they arise.
Learning Objectives: By utilzing this poster, readers will: 1) Gain a better understanding of potential complications of flow diversion treatment, 2) Discuss potential etiologies underlying acute flow diverter migration