Strategy-Specific Complication Phenotypes in Ophthalmic-Segment Ica Aneur b bysms: A Three-Patient Case Series Across Flow Diversion (Sac To FDS) and Primary Coiling

Background: Ophthalmic-segment internal carotid artery aneurysms (ICA-OphA) present unique therapeutic challenges given factors like their location, variable rupture status, and propensity for treatment-related complications. In fact, despite innovations in endovascular therapy—flow-diversion stents (FDS), stent-assisted coiling (SAC), and primary coiling—inter-patient complication profiles differ considerably. These three-cases in series highlight distinct complication phenotypes associated with strategy-specific management of ophthalmic-segment aneurysms. Methods: This series is a retrospective review of three females (46–67 y) with ICA-OphA aneurysms treated by the following: (1) flow-diverting stent (FDS), (2) stent-assisted coiling (SAC) with interval overlapping FDS, and (3) primary coiling. We then discuss clinical courses, imaging, peri/post-operative complications, and discharge outcomes for the three cases. Results: • Patient 1 (FDS, ruptured) o Presents fisher 3 SAH from right ICA-OphA aneurysm (7×9 mm). After DAPT loading and FDS, the patient developed delayed in-stent thrombosis with hemispheric infarction requiring decompressive hemicraniectomy. The patient discharged GCS 15 with hemiplegia. • Patient 2 (SAC→FDS, unruptured) o Presents monocular vision loss with ICA-OphA aneurysm (12×8 mm). Initial SAC followed by regrowth at 6 months. The patient treated with overlapping FDS. 6-month angiography showed complete occlusion with vision stable. • Patient 3 (Primary coiling, ruptured) o Presents fisher 2 SAH from ICA-OphA aneurysm (4×9 mm). Intra-procedural rupture during catheterization managed with rapid coil occlusion. The CT showed focal ICH. The patient discharged GCS 15 with persistent aphasia and hemiparesis. Conclusion: Across three strategies, we observed distinct complication phenotypes including delayed thrombosis after FDS, interval regrowth after SAC requiring FDS, and intra-operative rupture with primary coiling. The 3 female-patient series emphasize that recognizing patterned risks is critical for strategy selection, DAPT planning/monitoring, surveillance intervals, and patient counseling. Learning Points: • Technique matters: FDS—watch for delayed thrombotic events; SAC—plan follow-up for regrowth; primary coiling—highest intraprocedural rupture risk. • Surveillance should match strategy: early imaging for thrombotic complications after FDS; 3–6 mo angiography after SAC to detect recurrence. • Optimize antiplatelet/anticoagulation protocols and platelet-function testing when using FDS. • Document Raymond–Roy class and neurologic outcomes to correlate mechanism and prognosis. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany