Abstract
Intracranial aneurysms located at the bifurcation of the middle cerebral artery (MCA) can often be challenging for the neurointerventionalist. We aimed to evaluate the efficacy and safety of flow diverting stents (FDS) in the treatment of these aneurysms. We retrospectively reviewed our prospectively maintained database to collect information for all patients with unruptured saccular bifurcation MCA aneurysms treated with FDS between January 2010 and January 2016. In addition to demographic data, we recorded the location, aneurysm characteristics, previous treatments, number and type of FDS, complications, and clinical and angiographic follow-up. Our search identified 13 patients (7 males) with an average age of 61.7 years (47-74 years). All patients had a single bifurcation aneurysm of the MCA, and none of the aneurysms were acutely ruptured. The average fundus size of the saccular aneurysms was 3 mm (range 1.5-10 mm). Follow-up studies were available for 12 patients. Based on the most recent follow-up angiograms, six aneurysms (50%) were totally occluded; five aneurysms (41.7%) showed only a small remnant; and one aneurysm (8.3%) remained unchanged. One patient suffered from an ischemic stroke with resultant permanent hemiparesis (mRS 3). In another case, there was an in-stent thrombosis during the intervention, which resolved upon intra-arterial infusion of Eptifibatide (mRS 0). There were no intra-operative vessel or aneurysm ruptures and no mortalities. Angiography of the covered MCA branches showed no change in the caliber or flow of the vessel in six (50%), a reduction in caliber in five (41.7%), and a complete occlusion in one (8.3%). All caliber changes and occlusions of the vessels were asymptomatic. In our series, 91.7% of treated MCA bifurcation aneurysms were either completely occluded or showed only a small remnant with a good safety profile. Flow diversion of MCA bifurcation aneurysms should be considered as an alternative treatment strategy when microsurgical clipping or alternative endovascular treatment options are not feasible.
Highlights
Since the publication of the International Subarachnoid Aneurysm Trial, intracranial aneurysms are being increasingly treated via the endovascular approach as an alternative for craniotomy and surgical clipping [1]
We chose to categorize aneurysms arising at the first main division of the M1 trunk and those arising at an early division of a dominant superior or inferior trunk as middle cerebral artery (MCA) bifurcation aneurysms
Twelve aneurysms were located at the fist main MCA bifurcation, one aneurysm was located at the bifurcation of each of the superior and inferior trunk
Summary
Since the publication of the International Subarachnoid Aneurysm Trial, intracranial aneurysms are being increasingly treated via the endovascular approach as an alternative for craniotomy and surgical clipping [1]. Aneurysms of the middle cerebral artery (MCA) remain, challenging for the neurointerventionist as they most commonly arise at a bifurcation of the vessel and frequently have a wide neck that can incorporate one or more branches [2], rendering traditional coiling difficult and necessitating the use of adjunctive devices such as balloon remodeling [3,4,5,6,7] or stent-assisted coiling [8,9,10,11,12]. The role of flow diverter stents (FDS) in treating bifurcation aneurysms remains, unclear. We review our experience in treating MCA bifurcation aneurysms with flow diversion as the primary approach or secondary therapy after previous coiling or clipping with subsequent recanalization/ aneurysm residual. Intracranial aneurysms located at the bifurcation of the middle cerebral artery (MCA) can often be challenging for the neurointerventionalist. We aimed to evaluate the efficacy and safety of flow diverting stents (FDS) in the treatment of these aneurysms
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