to know in the setting of stroke etiology, perfusion dynamics in stenosis, neurovascular compression of cranial nerves, and WADA testing. Certain variants can be detrimental in the setting of pituitary surgery and provide guidance on surgical approach prior to neurological surgery.

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OBJECTIVE Pseudoaneurysms (PSAs) are complex vascular lesions. Flow diversion has been proposed as an alternative treatment to parent artery occlusion that preserves laminar flow. The authors of the present study investigated the safety and short-term (< 1 year) and long-term (≥ 1 year) aneurysm occlusion rates following the treatment of intracranial and extracranial PSAs using the Pipeline embolization device (PED). METHODS An electronic database search for full-text English-language articles in Ovid MEDLINE and Epub Ahead of Print, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus was conducted following the PRISMA guidelines. Studies of any design including at least 4 patients with intracranial or extracranial PSAs treated using a PED were included in this analysis. The primary outcome of interest was the rate of peri- and postprocedural complications. Secondarily, the authors analyzed the incidence of complete aneurysm occlusion. RESULTS A total of 90 patients with 96 PSAs across 9 studies were included. The mean age was 38.2 (SD 15.14) years, and 37.8% of the patients were women. The mean PSA size was 4.9 mm. Most PSAs were unruptured, and the most common etiology was trauma (n = 32, 35.5%), followed by spontaneous formation (n = 21, 23.3%) and iatrogenic injury (n = 19, 21.1%). Among the 51 (53.1%) intracranial and 45 (46.9%) extracranial PSAs were 19 (19.8%) dissecting PSAs. Sixty-six (77.6%) PSAs were in the internal carotid artery and 10 (11.8%) in the vertebral artery. Thirty-three (34.4%) PSAs were treated with ≥ 2 devices, and 8 (8.3%) underwent adjunctive coiling. The mean clinical and angiographic follow-up durations were 10.7 and 12.9 months, respectively. The short-term (< 1 year) and long-term (≥ 1 year) complete occlusion rates were 79% (95% CI 66%–88%, p = 0.82) and 84% (95% CI 70%–92%, p = 0.95), respectively. Complication rates were 8% for iatrogenic dissection (95% CI 3%–16%, p = 0.94), 10% for silent thromboembolism (95% CI 5%–21%, p = 0.77), and 12% for symptomatic thromboembolism (95% CI 6%–23%, p = 0.48). No treatment-related hemorrhage was observed. The overall mortality rate at the last follow-up was 14%. CONCLUSIONS The complete occlusion rate for PSAs treated with the PED was high and increased over time. Although postprocedural complications and mortality were not insignificant, flow diversion represents a reasonably safe option for managing these complex lesions.

Introduction Flow diversion with the Pipeline Embolization Device (PED) is increasingly used to treat intracranial aneurysms with high obliteration rates and low morbidity. However, long-term (!1 year) angiographic and clinical outcomes still require further investigation. The aim of this study was to compare the occlusion and complication rates for small (<10 mm) versus large (10-25 mm) aneurysms at long-term following treatment with PED. Methods A systematic review and meta-analysis were performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We conducted a comprehensive search of English language databases including Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Our studies included a minimum of 10 patients treated with PED for small vs. large aneurysms and with at least 12 months of follow-up. The primary safety endpoint was the rate of clinical complications measured by the occurrence of symptomatic stroke (confirmed clinically and radiographically), intracranial hemorrhage, or aneurysmal rupture. The primary efficacy endpoint was the complete aneurysm occlusion rate. Results Our analysis included 19 studies with 1,277 patients and 1,493 aneurysms. Of those, 1,378 aneurysms met our inclusion criteria. The mean age was 53.9 years, and most aneurysms were small (89.75%; N= 1,340) in women (79.1%; N= 1,010). The long-term occlusion rate was 73% (95%, CI 65% to 80%) in small compared to 84% (95%, CI 76% to 90%) in large aneurysms (p<0.01). The symptomatic thromboembolic complication rate was 5% (95%, CI 3% to 9%) in small compared to 7% (95%, CI 4% to 13%) in large aneurysms. (p=0.01). The rupture rate was 2% vs. 4% (p = 0.92), and the rate of intracranial hemorrhage was 2% vs. 4% (p=0.96) for small vs. large aneurysms, respectively; however, these differences were not statistically significant. ConclusionThe long-term occlusion rate after PED treatment is higher in large vs. small aneurysms. Symptomatic thromboembolic rates with stroke are also higher in large vs. small aneurysms. The difference in the rates of aneurysm rupture and intracranial hemorrhage was insignificant. Although the PED seems a safe and effective treatment for small and large aneurysms, further studies are required to clarify how occlusion rate and morbidity are affected by aneurysm size.