Журнал сосудистой медицины и хирургии

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A Rare Case of Flow-Diversion of a Fenestration of the Internal Carotid Artery with an Associated Aneurysm and a Resected Ipsilateral Cavernous Malformation

Mihail Petrov, Teodora Sakelarova, Nikolay Velinov, Ivan Martinov, Nikolay Gabrovsky

Introduction: Fenestration of the Internal Carotid Artery (ICA) is an extremely rare congenital anatomical variation. Even more uncommon is the concomitant presence of another vascular pathology-an ipsilateral cerebral aneurysm, ipsilateral arterio-venous malformation.

Research question: We present a clinical case of a patient with a fenestration of the right ICA with associated aneurysm, treated with a Pipeline flow-diverter stent, and a resected ipsilateral cavernous malformation. To our knowledge, this is the first reported case with this constellation.

Materials and Methods: A 44-year-old male patient presented with a generalized epileptic seizure. The MRI scan revealed a right frontal Cavernous Malformation (CM). The conducted Digital Subtraction Angiography (DSA) showed a fenestration of the right ICA and an associated aneurysm.

Results: In the first stage the CM was resected. The patient was started on double antiplatelet therapy postoperatively. In the second stage a Pipeline flow-diverter stent was inserted in the right ICA, covering the fenestrated segment and the associated aneurysm.

Discussion and conclusion: The presence of cerebral vascular malformations (AVMs, CMs) and an associated aneurysm in the fenestrated segment of the ICA should raise the discussion what to treat first and how. In our case due to the need for antiplatelet therapy for the implantation of a flow-diverter stent, the CM was operated on first. In ICA fenestrations with associated aneurysm with a dominant arterial channel the implantation of a flow-diverter stent is an elegant method of eliminating the aneurysm from the circulation and restoring hemodynamics in the affected arterial segment.