Advances in stroke: Advances in interventional radiology 2013

Expanding Indications for Flow Diverters: Ruptured Aneurysms, Blister Aneurysms, and Dissecting Aneurysms

BACKGROUND

The safety and efficacy of flow diversion (FD) in the treatment of cerebral aneurysms have been reported by many studies. FD has enabled the treatment of complex aneurysms and aneurysms that were previously untreatable by conventional means. It has achieved high rates of obliteration with essentially no recanalization, and its indications have continued to expand, now including ruptured aneurysms, blister aneurysms, and dissecting aneurysms.

OBJECTIVE

To provide a review on the outcomes of studies covering the use of FD in the settings of ruptured, blister, and dissecting aneurysms. In addition, to discuss dual antiplatelet therapy (DAPT) used in preparation for FD deployment in these scenarios, including associated complications with DAPT use in the acute rupture setting.

METHODS

References for this topical review were identified by PubMed searches between January 2000 and January 2019. The search terms “aneurysm”, “flow diverter”, “stent”, “pipeline”, “ruptured”, “blister”, and “dissecting aneurysms” were used.

RESULTS

FD carries a higher complication rate in the acute rupture setting than for unruptured aneurysms. Patient selection is of paramount importance for achieving good functional and angiographic outcomes. DAPT still remains challenging, especially in ruptured aneurysms. Advancements in surface modification of flow diverters can reduce the risk of thromboembolism and perhaps lead to a safer antiplatelet regimen.

CONCLUSION

In summary, FD shows promise to be an effective treatment for ruptured, blister, and dissecting aneurysms.

Treatment of ruptured intracranial aneurysms with the pipeline embolization device

BACKGROUND

The pipeline embolization device (PED) has been used for treatment of unruptured aneurysms. Little is known about the use of the PED in ruptured aneurysms.

OBJECTIVE

To assess the safety and efficacy of the PED in ruptured intracranial aneurysms.

METHODS

This is a case series with prospective data collection on 20 patients with freshly ruptured aneurysms who were treated with PED (with or without adjunctive coiling) at 2 cerebrovascular centers. Patients were loaded with aspirin and clopidogrel or received an infusion of tirofiban intraoperatively.

RESULTS

Hunt and Hess grades were I in 7 patients (35%), II in 9 (45%), and III in 4 (20%). The mean duration from hemorrhage to PED placement was 7±7.0 days. A single device was used in all but 1 patient (95%). The procedure was staged in 20%. There was only 1 complication (5%); this was a fatal intraoperative aneurysm dome rupture that occurred during adjunctive coil deployment. Adjunctive coiling was used in 30%. No patient required an invasive procedure after PED placement. Follow-up angiography (mean, 5.3±4.2 months; range, 2-12 months) showed 100% occlusion in 12 (80%) and incomplete occlusion in 3 patients (20%). At latest follow-up, 19 patients achieved a favorable outcome (modified rankin scale 0-2).

CONCLUSION

In our preliminary experience, treatment of ruptured aneurysms with the PED was associated with low complication rates, high occlusion rates, and favorable outcomes. These findings suggest that PED may be a safe and effective option for patients with favorable Hunt and Hess grades and aneurysms difficult to treat with conventional methods.