Part of malignant aneurysm series — to show that aggressive aneurysms require aggressive solutions. The kind of partially thrombosed, expanding aneurysm where endoluminal strategies like stent-coil are not the right answer. Multi-device FD, parent vessel sacrifice, flow reversal are.

This is a not so aggressive looking PCOM. Not small but also not very ominous-appearing

Post 2 PEDs. Typically, with a good P1, this is plenty. Note strategic high coverage over the aneurysm and single choroidal coverage

Two years later — two more pipes are added. Can one argue this is a mistake — if two did not do it, will four? Its a valid point, as you can guess

One year after, still here… What we dont understand is why. What we do know is that one Pipe would have surely not been enough. It is also possible that having all these Pipes stopped the aneurysm from growing much more… Never know, but we have sure seen what happens when these are underterated

What to do? Coiling it through P1 risks the thalamoperforator. Undercoiling is not a good idea. The solution is to Pipe across the P1

This is changing flow dynamics for sure. One year later, finally gone. Note how the aneurysm deflated, closing the distance between the two pipe constructs.

Conclusion — real flow modifications are necessary to address this problem.

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