• Victoria E Fischer, Samon Tavakoli, Pavel Rodriguez, Lee A Birnbaum, and Justin R Mascitelli.
• Division of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
• World Neurosurg. 2021 Jan 1; 145: 51-56.

BackgroundFlow diversion with or without coil embolization has become the first-line treatment for large or giant paraclinoid internal carotid artery intracranial aneurysms. Oftentimes, these sizable aneurysms impose anatomical challenges to endovascular treatment through limiting both distal outflow access and maintenance of distal vessel purchase during catheter reduction, which are required for successful stent placement. Various strategies to obtain and maintain distal access within the parent vessel have been described previously; however, new techniques may need to be employed when more standard maneuvers fail.Case DescriptionThis paper depicts a case of successful flow diversion of a near-giant internal carotid artery ophthalmic aneurysm in a middle-aged female patient using a balloon-assisted technique, designated the Ricochet-Scepter technique, to achieve distal outflow access followed by secondary system reduction via a stent retriever after standard maneuvers had failed.ConclusionsGiant, wide-neck aneurysms present treatment challenges that may require using adjunctive devices and advanced endovascular techniques. When routine strategies for gaining distal outflow access fail, the Ricochet-Scepter technique is a viable option for achieving distal access.Copyright © 2020 Elsevier Inc. All rights reserved.

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