Flow Diverter Implantation for Intracranial Aneurysm with Concomitant Cerebral Infarction in the Chronic Phase: A 3-Year Complete Obliteration Case

BACKGROUND Intracranial aneurysms (IAs) coexisting with chronic-phase cerebral infarction (CI) present unique therapeutic challenges. Antiplatelet therapy for infarction increases bleeding risks during aneurysm treatment, whereas delayed intervention may raise rupture risks. Flow diverters (FDs) have transformed IA management, but evidence regarding their safety and efficacy in patients with concomitant chronic CI remains scarce. CASE REPORT A 56-year-old man presented with slurred speech and right-sided weakness caused by subacute CI in the left basal ganglia. Imaging identified a small, unruptured IA (2.50×1.74×1.54 mm) in the left internal carotid artery ophthalmic segment. The aneurysm was asymptomatic, without corresponding neurological deficits or headaches. Dual antiplatelet therapy (DAPT: aspirin 100 mg/day and clopidogrel 75 mg/day) and atorvastatin (20 mg/day) were initiated on Day 1. By Day 25 (chronic infarction phase, ≥21 days post-onset, with stabilized neurological symptoms), an FD (Pipeline™ Flex, 4.25×16 mm; Medtronic, USA) was implanted. Postoperatively, DAPT was maintained for 6 months to mitigate FD-related thromboembolic risk and prevent CI recurrence, after which single antiplatelet therapy (aspirin 100 mg/day) was continued. Follow-up at 12 and 36 months demonstrated complete aneurysm obliteration and full recovery of motor and speech functions without recurrent ischemia or hemorrhage. CONCLUSIONS FD implantation was safely performed and resulted in favorable outcomes for an unruptured IA in a patient with chronic-phase CI. Appropriate timing during the chronic phase and individualized antiplatelet management appeared to balance infarction control and aneurysm occlusion. Further research is warranted to determine broader applicability of these findings.