• David Fiorella, Michael E Kelly, Felipe C Albuquerque, and Peter K Nelson.
• Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona 85013, USA. david.fiorella@bnaneuro.net
• Neurosurgery. 2009 Feb 1;64(2):212-7; discussion 217.

ObjectiveTo demonstrate the curative reconstruction of a giant circumferential basilar trunk aneurysm using the Pipeline embolization device (PED) (Chestnut Medical Technologies, Inc., Menlo Park, CA) alone, without embolization coils.MethodsA 13-year-old female patient was referred for the treatment of a 4-cm, partially thrombosed, circumferential midbasilar trunk aneurysm. Her presenting symptoms included headache, nystagmus, and left upper-extremity ataxia. Open surgical and conventional endovascular treatment options were thought to be of unacceptably high risk and unlikely to achieve a definitive treatment. The patient underwent PED treatment under a Food and Drug Administration compassionate use exemption.ResultsAn endovascular construct was built across the affected segment of the basilar trunk with 7 serially placed, telescoping PEDs, which bridged the 29-mm aneurysm neck. Completion angiography demonstrated considerably decreased flow into the aneurysm, with stasis persisting into the venous phase of angiography. No technical complications were encountered. No new neurological symptoms were evident, and the patient's original presenting symptoms resolved completely within 24 hours after the procedure. She was discharged on postoperative Day 3. Computed tomography performed on postoperative Day 5 demonstrated no change in the size of the collective aneurysm-thrombus mass. Conventional angiography performed on postoperative Day 7 showed anatomic reconstruction of the basilar artery and complete occlusion of the circumferential aneurysm. The patient remains neurologically normal.ConclusionThe PED provides a safe and definitive constructive treatment option for large, giant, and fusiform/circumferential aneurysms. The PED can achieve complete aneurysm occlusion without embolization coils. When applied judiciously, the PED may be used safely in vascular segments that give rise to eloquent perforators.

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