Flow Diverter Treatment and 1-Year Follow-Up for a Complex Anterior Communicating Artery Aneurysm: a case report

Flow Diverter Treatment and 1-Year Follow-Up for a Complex Anterior Communicating Artery Aneurysm: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Flow Diverter Treatment and 1-Year Follow-Up for a Complex Anterior Communicating Artery Aneurysm: a case report Yan Fu, Miaomiao Wang, Zhiyong Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8995977/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Flow diverters have revolutionized intracranial aneurysm management. However, their application in the anterior communicating artery complex—a region densely populated with perforating vessels—remains relatively contraindicated, primarily due to significant concerns regarding perforator occlusion and in-stent thrombosis. Here we report a 54-year-old male patient with multiple irregular aneurysms located in the anterior communicating artery complex. Flow diverter placement was performed under general anesthesia. Postoperatively, the patient developed an acute cerebral ischemic event, which resolved completely with active adjustment of the antithrombotic regimen. No recurrence of symptoms was observed during the one-year follow-up period, and subsequent angiography confirmed complete aneurysm occlusion. Therefore, with adequate preoperative planning and appropriate postoperative antithrombotic management, flow diverter for complex multiple anterior communicating artery aneurysms is feasible. Future large-sample studies are needed to validate these findings. Anterior communicating artery aneurysm flow diverter implantation tirofiban ischemic event antiplatelet therapy Figures Figure 1 Introduction The anterior communicating artery (ACoA) is a key component of the Willis circle, where it connects the A2 segments of the bilateral anterior cerebral arteries. It represents a common site for intracranial aneurysms, accounting for approximately 35% of cases [ 1 – 5 ]. The complex anatomy and hemodynamic environment of this region, along with frequent anatomical variations (such as asymmetry of the A1 segments or altered flow direction), contribute to an increased risk of aneurysm rupture [ 6 ]. This risk is further elevated when aneurysms exhibit multiple or irregular morphological features (e.g., daughter sacs or wall lobulations), which enhance wall shear stress and lead to focal wall thinning [ 7 , 8 ]. Once ruptured, ACoA aneurysms often affect both anterior and posterior circulation territories, resulting in severe neurological deficits and posing significant therapeutic challenges [ 9 ]. We present a patient with the treatment of complex multiple anterior communicating artery aneurysms with flow diverter stent and one-year follow-up. Case Description A 54-year-old male patient was admitted to the hospital with a one-month history of a detected anterior communicating artery aneurysm. His past medical history included chronic hypertension and hyperlipidemia, both well-controlled with long-term medication. Three years ago, he had experienced a cerebral infarction without residual neurological deficits. During the same period, severe stenosis of the right middle cerebral artery M1 segment was identified and treated conservatively with medication. He had a smoking history of over 20 years but had since quit, with no history of alcohol use or significant occupational exposure. Upon admission, neurological examination revealed no positive signs, and cranial magnetic resonance imaging (MRI) showed no evidence of fresh ischemic lesions. The routine biological tests display a slight hyperlipidemia and hyperhomocysteinemia without any other abnormalities. Digital subtraction angiography (DSA) revealed occlusion of the right middle cerebral artery (MCA) with a patent anterior communicating artery. Left carotid artery injection demonstrated filling of the right anterior cerebral artery via collateral circulation, which supplied blood to the ipsilateral middle cerebral artery territory. Three irregular aneurysms with daughter sacs were identified on both the superior and inferior walls of the anterior communicating artery by three-dimensional digital subtraction angiography(3D-DSA) (Fig. 1 A). The patient was started on dual antiplatelet therapy (aspirin 100 mg + clopidogrel 75 mg daily), along with antihypertensive and lipid-lowering medications. Three days after admission, the patient underwent flow-diverting stent placement for the anterior communicating artery aneurysms under general anesthesia. Intraoperatively, 3D-DSA was used to obtain precise measurements of the aneurysms and the parent artery. The three anterior communicating artery aneurysms measured 4.37 mm, 1.16 mm, and 2.88 mm in maximal diameter, with corresponding transverse diameters of 2.56 mm, 0.70 mm, and 1.82 mm, respectively. The diameter of the parent artery ranged from 2.12 mm to 2.58 mm. Using an aneurysm-loop microguidewire technique, the right anterior cerebral artery was superselected, and a 2.9 mm × 15 mm Echelon flow diverter was successfully deployed via a microcatheter(Fig. 1 B). Postoperatively, tirofiban (6ml/h) was infused for 48 hours. However, the patient developed right-lower-limb weakness when bridging to dual antiplatelet therapy (aspirin + clopidogrel). MRI revealed multiple scattered lesions in both cerebral hemispheres. Repeat DSA showed no new vascular abnormalities; and the stent was well-apposed without significant stenosis or thrombosis. The tirofiban was resumed (37.3 mL/h loading dose over 30 minutes, followed by 9.3 mL/h maintenance) for an additional 48 hours, after which antiplatelet therapy was switched to enteric-coated aspirin plus ticagrelor (the patient was identified as an intermediate metabolizer of CYP2C19). Following this adjustment, the patient’s condition stabilized without further transient ischemic attacks, and the National Institutes of Health Stroke Scale (NIHSS) score remained 0. At the one-month follow-up, no new neurological deficits were reported. Three-month follow-up angiography demonstrated significant shrinkage of the aneurysms(Fig. 1 C), and one-year follow-up angiography confirmed complete occlusion of the anterior communicating artery aneurysms with no residual fillingFig.1D). Discussion Several previous studies have summarized and analyzed different treatment techniques for anterior communicating artery aneurysms (such as conventional coiling, stent-assisted coiling, and surgical clipping). The results indicate that although these treatment methods achieve favorable rates of complete or near-complete angiographic occlusion in both the short and long term, the associated complications—including intraoperative rupture, vasospasm, aneurysm retreatment, and perioperative stroke leading to disability—as well as mortality risks remain non-negligible [ 10 – 12 ]. This case is notable for the following distinctive features: First, the patient presented with an asymptomatic intracranial aneurysm concurrent with occlusion of the right middle cerebral artery. The anterior communicating artery served as a critical compensatory pathway for blood supply to the right hemisphere, making preservation of its patency essential. Second, the aneurysms were located in the anterior communicating artery complex—a region known for its complex anatomy and high hemodynamic risk—and were multiple with daughter sacs, indicating an elevated risk of rupture. Third, the aneurysms exhibited multiple irregular morphologies, which would have made complete treatment in a single session challenging with conventional coil embolization. Given these considerations, surgical intervention was deemed necessary, and flow diverter placement was selected as the primary treatment strategy. The core mechanism of flow-diverting stents lies in reconstructing the inner vessel wall and altering hemodynamics at the aneurysm neck, thereby promoting intra-aneurysmal thrombosis and healing while maintaining patency of the parent artery and its branch vessels [ 13 – 14 ]. This makes them an ideal option for complex aneurysms, including those that are multiple, large/giant, wide-necked, or located in perforator-rich regions. Multiple studies have demonstrated that flow diverters can achieve favorable hemodynamic remodeling and high long-term occlusion rates in anterior communicating artery aneurysms [ 6 , 9 ]. Nevertheless, thromboembolism remains a serious complication of endovascular treatment for cerebral aneurysms. In the present case, postoperative ischemia occurred, and we propose the following potential mechanisms: (i) Flow diverter implantation may alter the direction and volume of blood flow through the anterior communicating artery and its collateral channels, particularly in patients dependent on collateral compensation, potentially leading to distal hypoperfusion. (ii)Repeated intraoperative device manipulation can cause endothelial injury, while the exposed metallic stent surface may activate platelets and promote local thrombus formation; subsequent thrombus detachment can induce distal ischemia [ 5 , 17 ]. (iii) In small-caliber vessels, the apposition of the flow diverter may be suboptimal. Micro-gaps between the stent and the vessel wall can create flow turbulence and stasis, increasing the risk of thrombosis and subsequent ischemia in the related brain territory [ 5 , 6 ]. (iv) Antiplatelet drug resistance, such as clopidogrel resistance in patients with CYP2C19 intermediate or poor metabolizer phenotypes, may lead to insufficient antithrombotic effect and elevate the risk of stent-related thrombus formation. The success of flow-diverting therapy critically depends on perioperative antithrombotic management. Recent studies indicate that optimized antithrombotic regimens—including individualized loading strategies and, when necessary, short-term intravenous tirofiban rescue—can significantly reduce thromboembolic events [ 15 , 16 , 18 , 19 ]. Miyama et al. (2021) highlighted the crucial role of perioperative antiplatelet management for the safety of flow-diverter treatment [ 15 ], while Matsubara et al. (2022) recommended regimen adjustments based on patient risk and drug-response profiles, including short-term rescue use of glycoprotein IIb/IIIa inhibitors such as tirofiban when indicated [ 16 , 17 ]. In this case, after the ischemic event occurred, the antithrombotic strategy was promptly adjusted: the tirofiban infusion was extended to enhance antiplatelet effect, and clopidogrel was switched to ticagrelor, which is unaffected by CYP2C19 polymorphisms. This approach effectively controlled the ischemic event without increasing hemorrhagic risk, offering practical experience for antithrombotic management in similar clinical scenarios. Conclusion This report presents a complex case of multiple anterior communicating artery aneurysms treated with a flow diverter and followed up comprehensively. The endovascular procedure successfully achieved complete aneurysm occlusion, while proactive perioperative antithrombotic management ensured stent patency and controlled thromboembolic events. Clinical reports on cases with similar distinctive hemodynamic backgrounds remain scarce; therefore, the experience from this case provides a valuable reference and confirms the potential application of this technology in complex scenarios. It should be noted, however, that flow diverters are not universally suitable for all anterior communicating artery aneurysms. A comprehensive evaluation of patient-specific arterial anatomy, hemodynamic characteristics, intraoperative manipulations, and perioperative antithrombotic strategy is essential for case selection. Further efforts are required to refine the criteria for using this technology and to explore its efficacy and risk-management protocols in the treatment of complex anterior communicating artery aneurysms. Declarations Funding The authors did not receive support from any organization for the submitted work. Author information Authors and Affiliations Department of Neurology, Beijing Geriatric Hospital, Beijing,China YanFu, Miaomiao Wang, Zhiyong,Zhang Neuromedicine Center, Beijing Geriatric Hospital, Beijing, China Zhiyong,Zhang Contributions YanFu wrote the main manuscript text and designed the figures. YanFu and Miaomiao Wang supported to review the references. Zhiyong,Zhang critically reviewed the article. All authors reviewed the manuscript. Corresponding author Correspondence to Zhiyong,Zhang. Ethics declarations This study was approved by the ethical committee of Beijing Geriatric Hospital. Consent to participate Informed consent was obtained from the patient included in the study. Consent for publication The subject in this case report gave written informed consent for publication of his personal and clinical details along with any identifying images in an anonymized format. Competing interests The authors have no relevant financial or non-financial interests to disclose. References Brown RD, Broderick JP. Unruptured intracranial aneurysms: Epidemiology, natural history, management options, and familial screening. Lancet Neurol. 2014;13:393–404. Kashtiara A, Beldé S, Menovsky T. Anatomical Variations and Anomalies of the Anterior Communicating Artery Complex. World Neurosurg. 2024;183:e218–27. 10.1016/j.wneu.2023.12.060 . Molyneux AJ, Kerr RS, Birks J, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol. 2009;8(5):427–33. 10.1016/S1474-4422(09)70080-8 . Keedy A. An overview of intracranial aneurysms. Mcgill J Med. 2006;9(2):141–6. Yarahmadi P, Kabiri A, Bavandipour A, Jabbour P, Yousefi O. Intra-procedural complications, success rate, and need for retreatment of endovascular treatments in anterior communicating artery aneurysms: a systematic review and meta-analysis. Neurosurg Rev. 2022;45(5):3157–70. 10.1007/s10143-022-01853-w . Withers J, Regenhardt RW, Dmytriw AA, Vranic JE, Marciano R, Rabinov JD. Circulation remodeling after flow diversion of an anterior communicating artery aneurysm: A case report. J Cerebrovasc Endovasc Neurosurg. 2023;25(3):311–5. 10.7461/jcen.2022.E2022.07.009 . Jabbarli R, Dinger TF, Darkwah Oppong M, et al. Risk Factors for and Clinical Consequences of Multiple Intracranial Aneurysms: A Systematic Review and Meta-Analysis. Stroke. 2018;49(4):848–55. 10.1161/STROKEAHA.117.020342 . Kaspera W, Ładziński P, Larysz P, et al. Morphological, hemodynamic, and clinical independent risk factors for anterior communicating artery aneurysms. Stroke. 2014;45(10):2906–11. 10.1161/STROKEAHA.114.006055 . Yamagami K, Hatano T, Nakahara I, et al. Long-term Outcomes After Intraprocedural Aneurysm Rupture During Coil Embolization of Unruptured Intracranial Aneurysms. World Neurosurg. 2020;134:e289–97. 10.1016/j.wneu.2019.10.038 . Fang S, Brinjikji W, Murad MH, Kallmes DF, Cloft HJ, Lanzino G. Endovascular treatment of anterior communicating artery aneurysms: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2014;35(5):943–7. 10.3174/ajnr.A3802 . O'Neill AH, Chandra RV, Lai LT. Safety and effectiveness of microsurgical clipping, endovascular coiling, and stent assisted coiling for unruptured anterior communicating artery aneurysms: a systematic analysis of observational studies. J Neurointerv Surg. 2017;9(8):761–5. 10.1136/neurintsurg-2016-012629 . Sattari SA, Shahbandi A, Lee RP, et al. Surgery or Endovascular Treatment in Patients with Anterior Communicating Artery Aneurysm: A Systematic Review and Meta-Analysis. World Neurosurg. 2023;175:31–44. 10.1016/j.wneu.2023.03.111 . Eller JL, Dumont TM, Sorkin GC, et al. The Pipeline embolization device for treatment of intracranial aneurysms. Expert Rev Med Devices. 2014;11(2):137–50. 10.1586/17434440.2014.877188 . Jee TK, Yeon JY, Kim KH, Kim JS, Jeon P. Flow Diversion for Cerebral Aneurysms: A Decade-Long Experience with Improved Outcomes and Predictors of Success. Brain Sci. 2024;14(8):847. 10.3390/brainsci14080847 . Published 2024 Aug 22. Miyama M, Matsukawa H, Sakakibara F, Uchida K, Shirakawa M, Yoshimura S. Perioperative Antiplatelet Management in the Flow-Diverter Treatment for Unruptured Cerebral Aneurysms: A Single-Center, Retrospective Analysis. World Neurosurg. 2024;183:e44–50. 10.1016/j.wneu.2023.10.128 . Matsubara H, Egashira Y, Enomoto Y. Antiplatelet Therapy in Endovascular Treatment of Cerebral Aneurysms. J Neuroendovasc Ther. 2025;19(1):2024–0016. 10.5797/jnet.ra.2024-0016 . Dornbos D 3rd, Katz JS, Youssef P, Powers CJ, Nimjee SM. Glycoprotein IIb/IIIa Inhibitors in Prevention and Rescue Treatment of Thromboembolic Complications During Endovascular Embolization of Intracranial Aneurysms. Neurosurgery. 2018;82(3):268–77. 10.1093/neuros/nyx170 . Xiao Z, Wang B, Yang Y et al. Safety and efficacy of tirofiban in the endovascular treatment of intracranial aneurysms: a systematic evaluation and meta-analysis. Neurosurg Rev. 2025;48(1):91. Published 2025 Jan 28. 10.1007/s10143-025-03208-7 Liu X, Lin Y, Ren B, et al. Safety and efficacy of short-term tirofiban combined with dual antiplatelet therapy after flow diverter placement for intracranial aneurysms: a multicenter retrospective study and nomogram for thromboembolic event prediction. Front Neurol. 2025;16:1689308. 10.3389/fneur.2025.1689308 . Published 2025 Nov 19. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8995977","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":604008866,"identity":"57895a0c-f24e-4e62-8a42-b0cc1d7705e4","order_by":0,"name":"Yan Fu","email":"","orcid":"","institution":"Beijing Geriatric Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Fu","suffix":""},{"id":604008868,"identity":"1e7f8d9f-3195-4cf6-b402-d9e98d979413","order_by":1,"name":"Miaomiao Wang","email":"","orcid":"","institution":"Beijing Geriatric Hospital","correspondingAuthor":false,"prefix":"","firstName":"Miaomiao","middleName":"","lastName":"Wang","suffix":""},{"id":604008871,"identity":"a6b875b5-e32c-44f2-9bc5-de22750ec0ae","order_by":2,"name":"Zhiyong Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYDACCcYGKANEVNjI8TMzH3xAgpYzacaS7WzJBvi1IDMY2w4nbjjPYyaAT4f87OY2iY87akGMZw+/AG0xPsxgxsBQYxONSwvjnINtkjPPHAcyjpkbywD9YnaYIe0Bw7G03AYcWpglEtukeduOARkJZtISQFuAWo4bMDYcxqmFDaaFTSL9m7Qk0C+bmxnbJPBp4YFoqQEycswkP4K8z8zMhleLhERis+XMtgNARk6ZNCiQJQ6zMRsk4PGL/Iz0hzc+ttWBGNskf4Cisv/8xwcfamxwagECFmCMHK4HKWDmgYkl4FYOAswfGBjqwCzGH/hVjoJRMApGwQgFACfXWNKrKmWqAAAAAElFTkSuQmCC","orcid":"","institution":"Beijing Geriatric Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zhiyong","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-02-28 14:09:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8995977/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8995977/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104583523,"identity":"a221495b-9558-4f38-9828-120a1f162743","added_by":"auto","created_at":"2026-03-13 15:21:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":122477,"visible":true,"origin":"","legend":"\u003cp\u003e3D-DSA showed three irregular aneurysms with daughter sacs on the anterior and posterior walls of the anterior communicating artery(A).Immediate postoperative angiographic findings: contrast agent retention, with some aneurysms not clearly visualized(B).Three-month follow-up angiography showing significant reduction in the size of the aneurysms(C).One-year follow-up angiography showing complete occlusion of the anterior communicating artery aneurysms with no residual filling(D).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8995977/v1/b9add154dd72e781fecfb479.png"},{"id":108659107,"identity":"b4bfaec5-48c0-4c99-ab11-8cd2ae09a3cd","added_by":"auto","created_at":"2026-05-07 04:40:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":261295,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8995977/v1/44e5df90-9d19-4026-8b4f-14988af9beba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFlow Diverter Treatment and 1-Year Follow-Up for a Complex Anterior Communicating Artery Aneurysm: a case report\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe anterior communicating artery (ACoA) is a key component of the Willis circle, where it connects the A2 segments of the bilateral anterior cerebral arteries. It represents a common site for intracranial aneurysms, accounting for approximately 35% of cases [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The complex anatomy and hemodynamic environment of this region, along with frequent anatomical variations (such as asymmetry of the A1 segments or altered flow direction), contribute to an increased risk of aneurysm rupture [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This risk is further elevated when aneurysms exhibit multiple or irregular morphological features (e.g., daughter sacs or wall lobulations), which enhance wall shear stress and lead to focal wall thinning [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Once ruptured, ACoA aneurysms often affect both anterior and posterior circulation territories, resulting in severe neurological deficits and posing significant therapeutic challenges [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. We present a patient with the treatment of complex multiple anterior communicating artery aneurysms with flow diverter stent and one-year follow-up.\u003c/p\u003e"},{"header":"Case Description","content":"\u003cp\u003eA 54-year-old male patient was admitted to the hospital with a one-month history of a detected anterior communicating artery aneurysm. His past medical history included chronic hypertension and hyperlipidemia, both well-controlled with long-term medication. Three years ago, he had experienced a cerebral infarction without residual neurological deficits. During the same period, severe stenosis of the right middle cerebral artery M1 segment was identified and treated conservatively with medication. He had a smoking history of over 20 years but had since quit, with no history of alcohol use or significant occupational exposure. Upon admission, neurological examination revealed no positive signs, and cranial magnetic resonance imaging (MRI) showed no evidence of fresh ischemic lesions. The routine biological tests display a slight hyperlipidemia and hyperhomocysteinemia without any other abnormalities. Digital subtraction angiography (DSA) revealed occlusion of the right middle cerebral artery (MCA) with a patent anterior communicating artery. Left carotid artery injection demonstrated filling of the right anterior cerebral artery via collateral circulation, which supplied blood to the ipsilateral middle cerebral artery territory. Three irregular aneurysms with daughter sacs were identified on both the superior and inferior walls of the anterior communicating artery by three-dimensional digital subtraction angiography(3D-DSA) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003eThe patient was started on dual antiplatelet therapy (aspirin 100 mg\u0026thinsp;+\u0026thinsp;clopidogrel 75 mg daily), along with antihypertensive and lipid-lowering medications. Three days after admission, the patient underwent flow-diverting stent placement for the anterior communicating artery aneurysms under general anesthesia. Intraoperatively, 3D-DSA was used to obtain precise measurements of the aneurysms and the parent artery. The three anterior communicating artery aneurysms measured 4.37 mm, 1.16 mm, and 2.88 mm in maximal diameter, with corresponding transverse diameters of 2.56 mm, 0.70 mm, and 1.82 mm, respectively. The diameter of the parent artery ranged from 2.12 mm to 2.58 mm. Using an aneurysm-loop microguidewire technique, the right anterior cerebral artery was superselected, and a 2.9 mm \u0026times; 15 mm Echelon flow diverter was successfully deployed via a microcatheter(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Postoperatively, tirofiban (6ml/h) was infused for 48 hours. However, the patient developed right-lower-limb weakness when bridging to dual antiplatelet therapy (aspirin\u0026thinsp;+\u0026thinsp;clopidogrel). MRI revealed multiple scattered lesions in both cerebral hemispheres. Repeat DSA showed no new vascular abnormalities; and the stent was well-apposed without significant stenosis or thrombosis. The tirofiban was resumed (37.3 mL/h loading dose over 30 minutes, followed by 9.3 mL/h maintenance) for an additional 48 hours, after which antiplatelet therapy was switched to enteric-coated aspirin plus ticagrelor (the patient was identified as an intermediate metabolizer of CYP2C19). Following this adjustment, the patient\u0026rsquo;s condition stabilized without further transient ischemic attacks, and the National Institutes of Health Stroke Scale (NIHSS) score remained 0. At the one-month follow-up, no new neurological deficits were reported. Three-month follow-up angiography demonstrated significant shrinkage of the aneurysms(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC), and one-year follow-up angiography confirmed complete occlusion of the anterior communicating artery aneurysms with no residual fillingFig.1D).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSeveral previous studies have summarized and analyzed different treatment techniques for anterior communicating artery aneurysms (such as conventional coiling, stent-assisted coiling, and surgical clipping). The results indicate that although these treatment methods achieve favorable rates of complete or near-complete angiographic occlusion in both the short and long term, the associated complications\u0026mdash;including intraoperative rupture, vasospasm, aneurysm retreatment, and perioperative stroke leading to disability\u0026mdash;as well as mortality risks remain non-negligible [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This case is notable for the following distinctive features: First, the patient presented with an asymptomatic intracranial aneurysm concurrent with occlusion of the right middle cerebral artery. The anterior communicating artery served as a critical compensatory pathway for blood supply to the right hemisphere, making preservation of its patency essential. Second, the aneurysms were located in the anterior communicating artery complex\u0026mdash;a region known for its complex anatomy and high hemodynamic risk\u0026mdash;and were multiple with daughter sacs, indicating an elevated risk of rupture. Third, the aneurysms exhibited multiple irregular morphologies, which would have made complete treatment in a single session challenging with conventional coil embolization.\u003c/p\u003e \u003cp\u003eGiven these considerations, surgical intervention was deemed necessary, and flow diverter placement was selected as the primary treatment strategy. The core mechanism of flow-diverting stents lies in reconstructing the inner vessel wall and altering hemodynamics at the aneurysm neck, thereby promoting intra-aneurysmal thrombosis and healing while maintaining patency of the parent artery and its branch vessels [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This makes them an ideal option for complex aneurysms, including those that are multiple, large/giant, wide-necked, or located in perforator-rich regions. Multiple studies have demonstrated that flow diverters can achieve favorable hemodynamic remodeling and high long-term occlusion rates in anterior communicating artery aneurysms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, thromboembolism remains a serious complication of endovascular treatment for cerebral aneurysms. In the present case, postoperative ischemia occurred, and we propose the following potential mechanisms: (i) Flow diverter implantation may alter the direction and volume of blood flow through the anterior communicating artery and its collateral channels, particularly in patients dependent on collateral compensation, potentially leading to distal hypoperfusion. (ii)Repeated intraoperative device manipulation can cause endothelial injury, while the exposed metallic stent surface may activate platelets and promote local thrombus formation; subsequent thrombus detachment can induce distal ischemia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. (iii) In small-caliber vessels, the apposition of the flow diverter may be suboptimal. Micro-gaps between the stent and the vessel wall can create flow turbulence and stasis, increasing the risk of thrombosis and subsequent ischemia in the related brain territory [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. (iv) Antiplatelet drug resistance, such as clopidogrel resistance in patients with CYP2C19 intermediate or poor metabolizer phenotypes, may lead to insufficient antithrombotic effect and elevate the risk of stent-related thrombus formation.\u003c/p\u003e \u003cp\u003eThe success of flow-diverting therapy critically depends on perioperative antithrombotic management. Recent studies indicate that optimized antithrombotic regimens\u0026mdash;including individualized loading strategies and, when necessary, short-term intravenous tirofiban rescue\u0026mdash;can significantly reduce thromboembolic events [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Miyama et al. (2021) highlighted the crucial role of perioperative antiplatelet management for the safety of flow-diverter treatment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], while Matsubara et al. (2022) recommended regimen adjustments based on patient risk and drug-response profiles, including short-term rescue use of glycoprotein IIb/IIIa inhibitors such as tirofiban when indicated [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this case, after the ischemic event occurred, the antithrombotic strategy was promptly adjusted: the tirofiban infusion was extended to enhance antiplatelet effect, and clopidogrel was switched to ticagrelor, which is unaffected by CYP2C19 polymorphisms. This approach effectively controlled the ischemic event without increasing hemorrhagic risk, offering practical experience for antithrombotic management in similar clinical scenarios.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis report presents a complex case of multiple anterior communicating artery aneurysms treated with a flow diverter and followed up comprehensively. The endovascular procedure successfully achieved complete aneurysm occlusion, while proactive perioperative antithrombotic management ensured stent patency and controlled thromboembolic events. Clinical reports on cases with similar distinctive hemodynamic backgrounds remain scarce; therefore, the experience from this case provides a valuable reference and confirms the potential application of this technology in complex scenarios. It should be noted, however, that flow diverters are not universally suitable for all anterior communicating artery aneurysms. A comprehensive evaluation of patient-specific arterial anatomy, hemodynamic characteristics, intraoperative manipulations, and perioperative antithrombotic strategy is essential for case selection. Further efforts are required to refine the criteria for using this technology and to explore its efficacy and risk-management protocols in the treatment of complex anterior communicating artery aneurysms.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors and Affiliations\u003c/p\u003e\n\u003cp\u003eDepartment of Neurology, Beijing Geriatric Hospital, Beijing,China \u003c/p\u003e\n\u003cp\u003eYanFu, Miaomiao Wang, Zhiyong,Zhang\u003c/p\u003e\n\u003cp\u003eNeuromedicine Center, Beijing Geriatric Hospital, Beijing, China\u003c/p\u003e\n\u003cp\u003eZhiyong,Zhang\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYanFu wrote the main manuscript text and designed the figures. YanFu and Miaomiao Wang supported to review the references. Zhiyong,Zhang critically reviewed the article. All authors reviewed the manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Zhiyong,Zhang.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethical committee of Beijing Geriatric Hospital.\u003c/p\u003e\n\u003cp\u003eConsent to participate\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe subject in this case report gave written informed consent for publication \u003c/p\u003e\n\u003cp\u003eof his personal and clinical details along with any identifying images in an \u003c/p\u003e\n\u003cp\u003eanonymized format. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBrown RD, Broderick JP. 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Published 2025 Nov 19.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anterior communicating artery aneurysm, flow diverter implantation, tirofiban, ischemic event, antiplatelet therapy","lastPublishedDoi":"10.21203/rs.3.rs-8995977/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8995977/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFlow diverters have revolutionized intracranial aneurysm management. However, their application in the anterior communicating artery complex\u0026mdash;a region densely populated with perforating vessels\u0026mdash;remains relatively contraindicated, primarily due to significant concerns regarding perforator occlusion and in-stent thrombosis. Here we report a 54-year-old male patient with multiple irregular aneurysms located in the anterior communicating artery complex. Flow diverter placement was performed under general anesthesia. Postoperatively, the patient developed an acute cerebral ischemic event, which resolved completely with active adjustment of the antithrombotic regimen. No recurrence of symptoms was observed during the one-year follow-up period, and subsequent angiography confirmed complete aneurysm occlusion. Therefore, with adequate preoperative planning and appropriate postoperative antithrombotic management, flow diverter for complex multiple anterior communicating artery aneurysms is feasible. Future large-sample studies are needed to validate these findings.\u003c/p\u003e","manuscriptTitle":"Flow Diverter Treatment and 1-Year Follow-Up for a Complex Anterior Communicating Artery Aneurysm: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 15:21:27","doi":"10.21203/rs.3.rs-8995977/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f153cf06-783f-4fbb-86b8-0a63ab9d8bca","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-07T04:31:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T04:41:36+00:00","index":47,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T04:39:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 15:21:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8995977","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8995977","identity":"rs-8995977","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}