Delayed rupture of intracranial aneurysms after placement of intra-luminal flow diverter

Abstract

Background Though flow diverter is a safe and efficient modality, some patients can experience delayed aneurysmal rupture. The mechanism of delayed rupture is still obscure to us. Methods We performed a systematic search in the PubMed database for patients with delayed rupture of intracranial aneurysms after flow diverter placement. Results A total of 36 articles reporting on 60 patients were included in the final analysis. Of the 49 patients with description of presenting symptoms, six (12.2%) patients were incidentally diagnosed, 39 (87.8%) patients were admitted for aneurysmal rupture or mass effect. Multiple flow diverters were used in 38.3% (18/47) of the patients. Coil assistance was applied in 13.0% (7/54) of the patients. Delayed aneurysmal rupture led to intracranial hemorrhage or carotid–cavernous sinus fistula (CCF) in 76.8% (43/56) and 23.2% (13/56) of the patients, respectively. Of the 55 patients with description of outcome, 14 (25.5%) patients achieved good recovery, one (1.8%) patient was severely disabled, 40 (72.7%) patients died. All of the patients in the CCF group survived and experienced good recovery. Conclusion Increased intra-aneurysmal pressure, destabilization of the aneurysm wall by intra-aneurysmal thrombus, persistent residual intra-aneurysmal flow, characteristics of the specific aneurysm, and mechanical injury by the flow diverter might conjointly contribute to the final delayed rupture. There has been no established preventive measure to decrease the incidence of delayed rupture yet. The treatment and outcome depend on the presentation of delayed rupture. Patients presenting with aneurysm-related intracranial hemorrhage have a dismal outcome. Those presenting with CCFs usually have a satisfactory recovery.

Endovascular Treatment of Large or Giant Basilar Artery Aneurysms Using the Pipeline Embolization Device: Complications and Outcomes

“…Delayed aneurysmal rupture is another potentially serious complication of FD treatment that can have a devastating outcome. Hou et al ( 34 ) performed a systematic review of patients who experienced delayed rupture after FD placement and concluded that increased intra-aneurysmal pressure, destabilization of the aneurysm wall by intra-aneurysmal thrombus, persistent residual intra-aneurysmal flow, large or giant size, presence of symptoms, and FD-induced mechanical injury might contribute to delayed rupture. In our series, four patients with aneurysm sizes ranging from 22 to 40 mm developed delayed rupture; three occurred from aneurysms located in the proximal segment, including two with a VBJ aneurysm that was treated with a single PED without coiling and contralateral vertebral sacrifice.…”

Treatment of carotid cavernous sinus fistulas with flow diverters. A case report and systematic review

“…27 As already mentioned, in cases where an FDD already exists, it can be used as a scaffold for further treatment either using additional FDDs or embolic agents. 16 , 20 , 21 , 28…”

Retrospective analysis of intracranial aneurysms after flow diverter treatment including color-coded imaging (syngo iFlow) as a predictor of aneurysm occlusion

“…18,[23][24][25] Investigation of the hemodynamic changes within cerebral aneurysms after FD treatment remains desirable, since associated complications such as delayed aneurysm growth or rupture remain topics in current literature. 15,[26][27][28] This study retrospectively examined the predictive value of various iFlow parameters after flow diverter treatment of cerebral aneurysms. Cattaneo et al previously described promising preclinical evaluation criteria, that are based on a comparison between intraluminal and intra-aneurysmal TDCs, aimed at the difference of maximum contrast agent intensity, delay between intensity peaks and ratio of intensity decrease.…”

“…18,23–25 Investigation of the hemodynamic changes within cerebral aneurysms after FD treatment remains desirable, since associated complications such as delayed aneurysm growth or rupture remain topics in current literature. 15,26–28…”