The pretzel sign: Angiographic pattern of tortuous intra-aneurysmal blood flow in a giant serpentine aneurysm

Giant serpentine aneurysms (GSAs) form a specific subgroup of giant cerebral aneurysms that have pathognomonic angiographic features. We report the angiographic findings of a GSA demonstrating a striking convoluted dynamic flow pattern, which we have called the ‘pretzel sign’. The aneurysm was successfully treated by permanent occlusion of the parent vessel using a detachable balloon. GSAs should be identified prior to treatment in view of their particular management requirements.