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Figure 3: Flow diversion embolization of a ruptured Fisher grade 3 blister aneurysm followed by severe vasospasm and delayed cerebral ischemia. A 47-year-old male with HIV, substance abuse, hypertension and asthma became unconscious and later had a seizure. He was intubated in the field. He presented as a Hunt and Hess 4, Fisher 3 subarachnoid hemorrhage (a). CT angiography of the brain showed a right internal carotid artery trunk blister aneurysm (b). He underwent placement of a lumbar drain for hydrocephalus and was loaded with aspirin and clopidogrel in preparation for flow diversion embolization. Intraoperative AP (c) and lateral (d) digital subtraction angiography imaging showed the presence of a dorsal wall internal carotid artery trunk blister aneurysm. The aneurysm was treated with a Pipeline® flow diversion device (lateral view; e) resulting in faint layering of contrast in the dome (eclipse sign; f). The patient followed commands on hospital day 4 and was extubated. His exam rapidly declined on hospital day 8, and he became comatose. Diagnostic cerebral angiography showed occlusion of the aneurysm (g), but bilateral severe anterior circulation vasospasm (g and i). Due to multiple strokes, the family elected to withdraw care (modified Rankin Scale 6)

Figure 3: Flow diversion embolization of a ruptured Fisher grade 3 blister aneurysm followed by severe vasospasm and delayed cerebral ischemia. A 47-year-old male with HIV, substance abuse, hypertension and asthma became unconscious and later had a seizure. He was intubated in the field. He presented as a Hunt and Hess 4, Fisher 3 subarachnoid hemorrhage (a). CT angiography of the brain showed a right internal carotid artery trunk blister aneurysm (b). He underwent placement of a lumbar drain for hydrocephalus and was loaded with aspirin and clopidogrel in preparation for flow diversion embolization. Intraoperative AP (c) and lateral (d) digital subtraction angiography imaging showed the presence of a dorsal wall internal carotid artery trunk blister aneurysm. The aneurysm was treated with a Pipeline® flow diversion device (lateral view; e) resulting in faint layering of contrast in the dome (eclipse sign; f). The patient followed commands on hospital day 4 and was extubated. His exam rapidly declined on hospital day 8, and he became comatose. Diagnostic cerebral angiography showed occlusion of the aneurysm (g), but bilateral severe anterior circulation vasospasm (g and i). Due to multiple strokes, the family elected to withdraw care (modified Rankin Scale 6)