Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study

Abstract

BACKGROUND Open surgery has traditionally been preferred for the management of bifurcation middle cerebral artery (MCA) aneurysms. Flow diverting stents present a novel endovascular strategy for aneurysm treatment. OBJECTIVE To add to the limited literature describing the outcomes and complications in the use of flow diverters for the treatment of these complex aneurysms. METHODS This is a multicenter retrospective review of MCA bifurcation aneurysms undergoing flow diversion. We assessed post-treatment radiological outcomes and both thromboembolic and hemorrhagic complications. RESULTS We reviewed the outcomes of 54 aneurysms treated with flow diversion. Four (7.4%) of the aneurysms had a history of rupture (3 remote and 1 acute). Fourteen (25.9%) of the aneurysms already underwent either open surgery or coiling prior to flow diversion. A total of 36 out of the 45 aneurysms (80%) with available follow-up data had adequate aneurysm occlusion with a median follow-up time of 12 mo. There were no hemorrhagic complications but 16.7% (9/54) had thromboembolic complications. CONCLUSION Flow diverting stents may be a viable option for the endovascular treatment of complex bifurcation MCA aneurysms. However, compared to published series on the open surgical treatment of this subset of aneurysms, flow diversion has inferior outcomes and are associated with a higher rate of complications.

Use of a p64 MW Flow Diverter with Hydrophilic Polymer Coating (HPC) and Prasugrel Single Antiplatelet Therapy for the Treatment of Unruptured Anterior Circulation Aneurysms: Safety Data and Short-term Occlusion Rates

“…DWI lesions were more prevalent in patients who underwent p64 MW HPC implantation for MCA/MCA-bifurcation aneurysms. By contrast, the results of a systematic review and metaanalysis published by Bond et al [18] revealed that DWI lesions developed in up to 67% of patients presenting with IAs after FD implantation. Silent ischemic events were reported in as many as 50.9-90% of cases involving the implantation of the uncoated Pipeline FD [21][22][23][24].…”

“…These findings represent a significant improvement over previously published data on the use of FD devices for MCA aneurysms. For example, (Aguilar) Pe ´rez et al [13] and Diestro et al [18] reported postprocedural complication rates of 15% and 16.7%, respectively, in patients with MCA-bifurcation aneurysms. However, we recognize that patients with an anticipated higher risk for ischemic complications were treated daily with subcutaneous LMW heparin for 4-6 weeks after FD treatment to reduce the risk of ischemic complications.…”

Distal Flow Diversion with Anti-Thrombotically Coated and Bare Metal Low-Profile Flow Diverters—A Comparison

“…Cagnazzo et al found 20% treatment-related complications with half of them having permanent clinical sequelae in an earlier study [ 43 ]. Diestro et al reported 16% thromboembolic complications after FD of the proximal MCA bifurcation in a collective of patients who required retreatment after a failed first surgical or endovascular attempt [ 44 ]. Contrary to that, Salem et al found that MCA-bifurcation aneurysms are treatable with much lower complication rates, the outcomes of their study being comparable to other, well consented FD locations [ 45 ].…”

Treatment of unruptured middle cerebral artery aneurysms: Systematic review in an attempt to perform a network meta-analysis

“…A meta-analysis reported by Cagnazzo et al ( 22 ), focused on the use of FDDs in MCA aneurysms, showed that the overall rate of complete/near-complete occlusion during follow-up was 78.7% (95% CI: 67.8%–89.7%) with a 12-month median duration, and the rate of treatment-related complications was 20.7% (95% CI: 14%–27.5%) of which approximately 10% was permanent. More recently, Diestro et al ( 23 ) published an international cohort study of 54 MCA bifurcation aneurysms compared to the published series on open surgical treatment; FDDs have inferior outcomes and are associated with a higher rate of complications. In this report, 16.7% (9/54) of the patients suffered a thromboembolic complication, and from the 45 aneurysms with available follow-up data, 20% did not have adequate occlusion with a median follow-up time of 12 months.…”