A 39-year-old male presented with a severe holocranial headache and vomiting since 1 day. CT showed diffuse SAH, DSA depicted an extremely wide-necked anterior communicating artery aneurysm incorporating bilateral A2 segment origins. The aneurysm measured 8x6x7mm, with a neck measuring 7mm. It was directed infer medially with a part of fundus superior to the anterior communicating artery region. Attempt to cannulate the ipsilateral A2 segments from each of the A1 segments was unsuccessful. Due to wide-neck, acute A1-A2 angle and bilateral incorporation of the A2 segments, treatment plan was changed to X-stenting. Wire was cannulated from right A1 to left A2, and second microcatheter was placed from left A1 to right A2. Another microcatheter was negotiated from the left ACA into the aneurysmal sac. 2 stents measuring 3x18mm and 3x24mm were deployed in an ‘X’-fashion. Subsequently, aneurysm was coiled through jailed microcatheter with 3 detachable platinum coils. Post-procedural angiography showed minimal residual opacification of inferior sac with patent stented segment and distal ACAs. There was good reconstruction of the anterior communicating artery complex. Repeat angiography on day 7 showed exclusion of the inferior sac of the aneurysm with minimal neck residual opacification. Follow-up CT angiography done at three months showed good patency of stents. Control DSA at 6 months showed complete exclusion of aneurysm with patent stents. At two years, patient was clinically stable and asymptomatic. This case illustrates the advantage of X-stenting for embolization of large, wide-neck, bilobed aneurysms with acute A1-A2 angle as an alternative to traditional treatment modalities. To the best of our knowledge, this is the first reported case of ‘X-stenting’ for anterior communicating artery aneurysm in India.

Keywords:X-Stenting; Cross-Stenting; Anterior Communicating Artery Aneurysms; Acomaa; Endovascular Techniques