Flow Diverter Stent for Middle Cerebral Artery Aneurysm [Neurosurgery Wiki]

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====== Flow Diverter Stent for Middle Cerebral Artery Aneurysm ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1HC7gWvsJppDwpFj5OkU_PCq1iLMQPRA14fQF9GKAIN3lGKgg-/?limit=15&utm_campaign=pubmed-2&fc=20230329133653}}
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[[Middle cerebral artery aneurysm]]s tend to be complex, with integrated branches and potentially [[wide neck]]s. [[Pipeline embolization device]] [[stent]]s are safe and effective in the [[middle cerebral artery aneurysm]], and the [[patency]] of the side and jailed branches is preserved in most cases. Higher [[occlusion]] and lower [[in-stent stenosis]] rates are seen with longer [[follow-up]] durations
((Soydemir E, Gündoğmuş CA, Türeli D, Andaç Baltacıoğlu N, Bayri Y, Baltacıoğlu F. Safety and efficacy of flow diverter stents in the treatment of middle cerebral artery aneurysms: a single-center experience and follow-up data. Diagn Interv Radiol. 2023 Mar 29;29(2):350-358. doi: 10.4274/dir.2022.211050. Epub 2023 Feb 1. PMID: 36988000.)).

However, compared to published series on the open surgical treatment of this subset of aneurysms, flow diversion has inferior outcomes and is associated with a higher rate of complications
((Diestro JDB, Adeeb N, Dibas M, Boisseau W, Harker P, Brinjikji W, Xiang S, Joyce E, Shapiro M, Raz E, Parra-Farinas C, Pickett G, Alotaibi NM, Regenhardt RW, Bernstock JD, Spears J, Griessenauer CJ, Burkhardt JK, Hafeez MU, Kan P, Grandhi R, Taussky P, Nossek E, Hong T, Zhang H, Rinaldo L, Lanzino G, Stapleton CJ, Rabinov JD, Patel AB, Marotta TR, Roy D, Dmytriw AA. Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study. Neurosurgery. 2021 Nov 18;89(6):1112-1121. doi: 10.1093/neuros/nyab365. PMID: 34624100.)).

[[Flow diverter]] for [[middle cerebral artery aneurysm treatment]] should be considered an alternative when traditional treatment methods are not feasible
((Bhogal P, AlMatter M, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. Flow
Diversion for the Treatment of MCA Bifurcation Aneurysms-A Single Centre
Experience. Front Neurol. 2017 Feb 2;8:20. doi: 10.3389/fneur.2017.00020.
eCollection 2017. PubMed PMID: 28210239; PubMed Central PMCID: PMC5288345.
)).

When performed in a select treatment group, high rates of aneurysm occlusion and protection against re-rupture can be achieved
((Cagnazzo F, Mantilla D, Lefevre PH, Dargazanli C, Gascou G, Costalat V.
Treatment of Middle Cerebral Artery Aneurysms with Flow-Diverter Stents: A
Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2017 Oct 5. doi:
10.3174/ajnr.A5388. [Epub ahead of print] PubMed PMID: 28982785.
)).

Longer angiographic follow-ups are needed to assess the morphologic outcome; immediate subtotal occlusions do not seem to be related to rupture
((Iosif C, Mounayer C, Yavuz K, Saleme S, Geyik S, Cekirge HS, Saatci I. Middle 
Cerebral Artery Bifurcation Aneurysms Treated by Extrasaccular Flow Diverters:
Midterm Angiographic Evolution and Clinical Outcome. AJNR Am J Neuroradiol. 2017 
Feb;38(2):310-316. doi: 10.3174/ajnr.A5022. Epub 2016 Dec 15. PubMed PMID:
27979794.
)).

Findings suggest that complete occlusion after endovascular treatment with FDD can be delayed (>6 months). Ischemic complications may occur as early or delayed, particularly at clopidogrel interruption
((Briganti F, Delehaye L, Leone G, Sicignano C, Buono G, Marseglia M, Caranci F,
Tortora F, Maiuri F. Flow diverter device for the treatment of small middle
cerebral artery aneurysms. J Neurointerv Surg. 2016 Mar;8(3):287-94. doi:
10.1136/neurintsurg-2014-011460. Epub 2015 Jan 20. PubMed PMID: 25603808.
)).

The [[Pipeline Embolization Device]] provides a safe and effective treatment alternative for wide-neck MCA aneurysms that give rise to a bifurcating or distal branch when other endovascular techniques are thought to be unfeasible or more risky
((Yavuz K, Geyik S, Saatci I, Cekirge HS. Endovascular treatment of middle
cerebral artery aneurysms with flow modification with the use of the pipeline
embolization device. AJNR Am J Neuroradiol. 2014 Mar;35(3):529-35. doi:
10.3174/ajnr.A3692. Epub 2013 Sep 26. PubMed PMID: 24072620.
)).

[[WEB]] flow disruption seems to be a promising technique for the treatment of complex MCA aneurysms, particularly those with a wide neck or unfavorable dome-to-neck ratio
((Pierot L, Klisch J, Cognard C, Szikora I, Mine B, Kadziolka K, Sychra V,
Gubucz I, Januel AC, Lubicz B. Endovascular WEB flow disruption in middle
cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical
results in a multicenter study. Neurosurgery. 2013 Jul;73(1):27-34; discussion
34-5. doi: 10.1227/01.neu.0000429860.04276.c1. PubMed PMID: 23615104.
)).

For Caroff et al. compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms
((Caroff J, Neki H, Mihalea C, D'Argento F, Abdel Khalek H, Ikka L, Moret J,
Spelle L. Flow-Diverter Stents for the Treatment of Saccular Middle Cerebral
Artery Bifurcation Aneurysms. AJNR Am J Neuroradiol. 2016 Feb;37(2):279-84. doi: 
10.3174/ajnr.A4540. Epub 2015 Sep 24. PubMed PMID: 26405085.
)).

Unsatisfactory occlusion rate in bifurcation aneurysms likely results from residual filling of the aneurysms in cases in which the jailed side branch remains patent
((Topcuoglu OM, Akgul E, Daglioglu E, Topcuoglu ED, Peker A, Akmangit I, Belen
D, Arat A. Flow Diversion in Middle Cerebral Artery Aneurysms: Is It Really an
All-Purpose Treatment? World Neurosurg. 2016 Mar;87:317-27. doi:
10.1016/j.wneu.2015.11.073. Epub 2015 Dec 23. PubMed PMID: 26723288.
)).
===== Systematic review and meta-analysis =====
A systematic search of PubMed, MEDLINE, and Embase was performed for studies published from 2008 to May 2017.

According to the [[Preferred Reporting Items for Systematic Reviews and MetaAnalyses]], Cagnazzo et al. selected studies with >5 patients describing angiographic and clinical outcomes after flow-diversion treatment of MCA aneurysms.

Random effects [[metaanalysis]] was used to pool the following outcomes: aneurysm occlusion rate, procedure-related complications, rupture rate of treated aneurysms, and occlusion of the jailed branches.

Twelve studies evaluating 244 MCA aneurysms were included in this meta-analysis. Complete/near-complete occlusion was obtained in 78.7% (95% CI, 67.8%-89.7%) of aneurysms. The rupture rate of treated aneurysms during follow-up was 0.4% per aneurysm year. The rate of treatment-related complications was 20.7% (95% CI, 14%-27.5%), and approximately 10% of complications were permanent. The mortality rate was close to 2%. Nearly 10% (95% CI, 4.7%-15.5%) of jailed arteries were occluded during follow-up, whereas 26% (95% CI, 14.4%-37.6%) had slow flow. Rates of symptoms related to occlusion and slow flow were close to 5%.

Small and retrospective series could affect the strength of the reported results.

Given the not negligible rate of treatment-related complications, flow diversion for MCA aneurysms should be considered an alternative treatment when traditional treatment methods are not feasible. However, when performed in this select treatment group, high rates of aneurysm occlusion and protection against re-rupture can be achieved
((Cagnazzo F, Mantilla D, Lefevre PH, Dargazanli C, Gascou G, Costalat V.
Treatment of Middle Cerebral Artery Aneurysms with Flow-Diverter Stents: A
Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2017 Oct 5. doi:
10.3174/ajnr.A5388. [Epub ahead of print] PubMed PMID: 28982785.
)).

===== Case series =====

[[Flow Diverter Stent for Middle Cerebral Artery Aneurysm case series]]

===== Case reports =====
Burrows et al. present the case of an adolescent with a middle cerebral artery (MCA) fusiform aneurysm which recurred following clip reconstruction and bypass. The aneurysm was successfully treated with endovascular flow diversion
((Burrows AM, Zipfel G, Lanzino G. Treatment of a pediatric recurrent fusiform
middle cerebral artery (MCA) aneurysm with a flow diverter. J Neurointerv Surg.
2013 Nov;5(6):e47. doi: 10.1136/neurintsurg-2012-010478.rep. Epub 2012 Nov 27.
PubMed PMID: 23188788.
)).