Cerebral aneurysms represent a heterogeneous group of intracranial vascular abnormalities that vary widely in morphology, clinical presentation, and risk of rupture [1, 2]. With the evolution of neuroimaging and endovascular technology, management has shifted toward minimally invasive, anatomy-specific approaches that enhance procedural safety and long-term durability [3, 4]. Despite these advancements, outcomes remain strongly influenced by timely diagnosis, individualized treatment selection, and vigilant monitoring for complications such as vasospasm or delayed cerebral ischemia [5].
This case series highlights the diverse spectrum of aneurysm presentations—from acute aneurysmal subarachnoid hemorrhage (SAH) to incidentally detected unruptured aneurysms—and demonstrates the successful management using simple coiling, balloon-assisted coiling, and flow-diverter placement.
A 43-year-old woman from Andhra Pradesh presented with severe headache for 10 days and was diagnosed with aneurysmal SAH. She came to our hospital for further management. Her CT angiogram showed thin SAH in the anterior interhemispheric fissure and bifrontal sulcal spaces (Fig. 1a) with a small aneurysm in the left distal anterior cerebral artery (DACA). Digital subtraction angiography (DSA) showed a narrow-necked bilobed saccular aneurysm in the left DACA measuring 4 x 6 mm (Fig. 1b, c). The anatomy was favorable, and simple coiling was performed using two detachable coils (Target 3mm x 8cm, 2mm x 4cm, Stryker) achieving near-complete exclusion of the aneurysm (Fig. 1d-f). The patient had an uneventful recovery and was discharged on post-procedure Day 2.
Figure 1: (a) Non-contrast Computed Tomography (CT) brain showing SAH in the anterior interhemispheric fissure and bilateral frontal sulci (white arrow) (b, c) DSA Left ICA angiogram lateral and frontal projections showing a small bilobed saccular aneurysm (black arrows) in the precallosal segment of left ACA (d) Fluoroscopic roadmap showing deployment of coils (black arrow) within the aneurysm sac through a microcatheter (e, f) Post coiling left ICA angiogram lateral and frontal projections showing absent filling of aneurysm sac (black arrows).
A 57-year-old woman presented with sudden severe headache followed by transient loss of consciousness. On arrival, she was drowsy but maintained a GCS of 15 with no focal deficits. CT brain revealed diffuse thick subarachnoid hemorrhage (SAH) (modified Fisher grade IV) with a small right paramedian frontal hematoma and intraventricular extension of bleed (Fig. 2a). CT angiography showed a small saccular anterior communicating artery (ACom) aneurysm.
She underwent DSA and endovascular coiling on the same day (Day 1 of ictus). The procedure was done under general anesthesia through right common femoral arterial access. DSA showed a bilobed, narrow-necked (~5 × 2.5 mm) aneurysm at the left A2–ACom junction (Fig. 2b). Balloon-assisted coiling was performed using two detachable coils (Target 3mm x 6cm, 2mm x 2.5cm, Stryker), achieving near-complete occlusion with preserved distal flow (Fig. 2c, d).
She was extubated the same night and monitored in the ICU. On Day 5, she developed sudden quadriparesis (power 1/5). MRI revealed multifocal acute lacunar infarcts (Fig. 2e). Urgent DSA demonstrated mild diffuse vasospasm (Fig. 2f). Intra-arterial Nimodipine (1.5 mg) and Milrinone (2.5 mg) were administered bilaterally, followed by IV Milrinone infusion. Her neurological status improved significantly, with motor power recovering to 4+/5. She was discharged on Day 16 in near-normal condition.
Figure 2: (a) Plain CT brain showing diffuse thick SAH (b) Right ICA angiogram showing the bilobed saccular aneurysm in Acom (black arrow) (c) Fluoroscopic roadmap depicting the coil mass (black arrow) in the aneurysm sac with balloon catheter (white arrow) across the aneurysm neck in left A2-ACA (d) Post coiling right ICA angiogram showing near complete exclusion of the aneurysm (black arrow) (e) Diffusion weighted MRI showing acute lacunar infarcts (black arrow) in the genu of corpus callosum and paramedian left frontal lobe (f) Right ICA angiogram showing mild diffuse narrowing of bilateral ACA, right MCA and its branches (compare with vessel calibre in Fig 2b).
A 75-year-old woman presented with transient bilateral blurring of vision. Ophthalmic evaluation was normal. MRI brain and orbits revealed bilateral supraclinoid ICA saccular aneurysms—larger on the left (11 × 8.5 mm) and a smaller right-sided aneurysm (3 × 2.5 mm) (Fig. 3a).
Given the size and potential mass effect of the left ICA aneurysm, DSA and endovascular treatment were planned. The aneurysm had a wide neck (Fig 3b, c); therefore, a flow diverter (Surpass Evolve 4.5 × 25 mm, Stryker) was deployed across the aneurysm neck, with distal landing in the terminal ICA and proximal landing in the horizontal cavernous segment (Fig. 3d, e). She recovered well and was discharged on Day 2 without any neurological deficits. Follow-up imaging is scheduled at 6 months to assess aneurysm occlusion and device patency.
Figure 3: (a) MR angiogram MIP image showing bilateral ICA aneurysms (black arrows) (b, c) DSA Left ICA angiogram frontal and lateral projections showing saccular aneurysm in the clinoidal and paraophthalmic segment of left ICA (black arrow) (d) Fluoroscopic spot image showing the flow diverter (FD) with optimal opening (black arrowheads) (e) Post FD placement angiogram showing stasis within the aneurysm sac (black arrow).
This case series illustrates the diversity of cerebral aneurysm presentations and emphasizes the importance of tailored endovascular management in optimizing patient outcomes. Careful assessment of aneurysm morphology, rupture status, and individual clinical factors remains central to selecting the most appropriate therapeutic strategy. The favourable recoveries observed across these cases—managed using simple coiling, adjunctive balloon-assisted techniques, and flow diversion—highlight the strengths of modern neurointerventional approaches in achieving safe, and effective aneurysm occlusion. Early diagnosis, prompt intervention, and meticulous post-procedural monitoring continue to be essential components in reducing morbidity and enhancing neurological recovery.
Sincere thanks to Dr. Anatharaman (Cardiology), Dr. Sridhar (ICU chief) and his entire team.
Dr Sathya Narayanan R Department of Intervention Radiology, Kauvery Hospital, Alwarpet, Chennai.
Dr Sriviruthi B. Department of Intervention Radiology, Kauvery Hospital, Alwarpet, Chennai.
