E1809. Imaging Spectrum of Complications Following Endovascular Intracranial Aneurysm Treatment
  1. Kenneth Huynh; University of California, Irvine
  2. Gillean Cortes; University of California, Irvine
  3. Jennifer Soun; University of California, Irvine
Endovascular management is the mainstay treatment option for intracranial aneurysms, with significant improvement in survival and morbidity in comparison to surgical clipping. In addition to coiling, novel endovascular techniques for complex intracranial aneurysms include the use of flow diverting stents, such as the FDA-approved Pipeline embolization device (PED). However, periprocedural risks are not entirely benign, with dire complications including intraprocedural aneurysm rupture, distal embolization, delayed aneurysm rupture, iatrogenic vascular injury, coil migration, and endoleak. A rare, delayed sequela includes hydrophilic polymer embolization (HPE) resulting in cerebral foreign body reaction, which has been reported in cases following endovascular procedures, especially with use of PED. Imaging and image-guided interventions play an important role in the diagnostic workup and treatment of intracranial aneurysm treatment related complications.

Educational Goals / Teaching Points
Review the endovascular techniques used in the management of intracranial aneurysms. Describe key imaging features of potential complications following aneurysm treatment. Discuss the diagnostic and treatment options available for management of complications following intracranial aneurysm treatment.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
This exhibit will present imaging features of complications following intracranial aneurysm treatment, which include intraprocedural aneurysm rupture, coil migration, endoleak after PED deployment, and HPE. Illustrations of these complications will be presented through a case-based review detailing the initial pathologic imaging, intraoperative digital subtraction angiography (DSA), and follow-up imaging with accompanying teaching points. Also discussed is HPE with subsequent foreign body reaction, which is a rare sequela resulting in parenchymal hemorrhage and ischemic infarction. Imaging features demonstrate scattered multiple enhancing lesions with surrounding edema on MR and variable magnetic susceptibility within the subcortical white matter and gray-white junction of the treated vascular territory. Differential diagnosis includes mycotic aneurysms and septic emboli; however, the foreign body reaction should resolve with corticosteroid therapy.

Although endovascular management is the treatment of choice for intracranial aneurysms, post-procedural complications can severely impact neurologic function and morbidity. Imaging helps guide prompt detection and management of aneurysm treatment complications, which can lower debilitation and increase likelihood of survival. Careful understanding of the different endovascular techniques and recognizing the imaging appearance of potential complications can help guide management of treatment-related complications.