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Flow Diversion for the Treatment of Intracranial Aneurysms

Brian P. Walcott, MD1; Christopher J. Stapleton, MD2; Omar Choudhri, MD1; Aman B. Patel, MD2
[+] Author Affiliations
1Department of Neurological Surgery, University of California, San Francisco
2Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, Boston
JAMA Neurol. 2016;73(8):1002-1008. doi:10.1001/jamaneurol.2016.0609.
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Importance  Brain aneurysms have traditionally been treated with surgical clipping or endovascular coiling techniques. With these modalities, many large or complex aneurysms remain difficult to treat. A new option, flow diversion, is now available to treat aneurysms.

Objective  To summarize the clinical progression of flow diversion technology, from an experimental treatment to a commonly used method to treat large or complex aneurysms.

Evidence Review  References for this topical review were identified by searches of PubMed and GoogleScholar between January 2000 and January 2016. The search terms aneurysm, flow diverter, stent, pipeline, FRED, SURPASS, SILK, flow diversion, and endovascular were used. Ongoing clinical trials were identified using the same search terms in the clinicaltrial.gov registry. Attention was focused on current indications, rates of complications, and areas of ongoing study in randomized clinical trials.

Findings  Flow diversion is a treatment approved by the US Food and Drug Administration for brain aneurysms that redirects blood flow away from the aneurysm, thereby promoting growth of a new endothelial lining across the aneurysm opening. Cure rates with this technology are high and complication rates are low.

Conclusions and Relevance  Flow diversion is a disruptive technology that has changed the way many brain aneurysms are treated. It is currently a preferred treatment option for large or giant wide-necked proximal internal carotid artery aneurysms. Ongoing randomized studies will help to more rigorously determine the efficacy of flow diversion.

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Figure 1.
Flow Diversion for Giant Carotid Artery Aneurysms

A and D, A woman in her mid-40s presented with unruptured, bilateral, giant paraclinoid segment aneurysms of the internal carotid artery. B and E, The patient underwent placement of flow-diverting stents, with a 1-week interval between procedures. Immediate reduction of flow into the aneurysm was noted on one side (B), and less so on the contralateral side (E). C and F, Follow-up angiography at 6 months demonstrates complete reconstruction of the parent artery with exclusion of the aneurysm.

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Figure 2.
Flow Diversion for Aneurysm Recurrence Following Coiling

A, A man in his early 50s experienced a subarachnoid hemorrhage from a ruptured ophthalmic segment carotid artery aneurysm. B, The aneurysm was primarily coiled. C, A combination of neck recurrence and coil compaction was noted on follow-up angiography. D, Follow-up angiography at 1 year showing placement of a flow-diverting stent across the aneurysmal segment. E, Follow-up angiography at 1 year demonstrated complete reconstruction of the parent artery, exclusion of the aneurysm, and preservation of the ophthalmic artery. F, Unsubtracted angiography demonstrates placement of the flow-diverting stent in the carotid artery.

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Figure 3.
Flow Diversion for Complex Anterior Cerebral Artery Aneurysm

A and B, A patient presented with an unruptured, large, and partially thrombosed aneurysm at the A1-A2 anterior cerebral artery junction. C, The aneurysm was treated with a flow-diverting stent, resulting in complete exclusion of the aneurysm. D, Unsubtracted angiography demonstrates the exact location of the flow-diverting stent.

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