Controversy surrounding flow diverters in the sylvian artery - Ep.1/4

• Flow diverter in the treatment of MCA aneurysms:

MCA aneurysms are mostly located at the bifurcation and tend to be widenecked. Another issue is that frequently incorporate one or more branch vessels1. Flow diversion has been used as an alternative technique for complex wide-neck. MCA aneurysms, incorporating >1 side branch or in cases of previous endovascular or surgical failure2-6. 

Flow diversion for MCA aneurysms should only be considered as salvage therapy when traditional treatment methods are unfeasible, given the 10% rate of permanent neurologic morbidity7. With the evolution of the endovascular technique and image acquisition, the possibility of using FD in this type of case has been used, although we do not have a consensus in the literature.

During SLICE 2024 we can see a great discussion about the treatment of an aneurysm in a MCA bifurcation with another aneurysm in the M1 segment with a fenestration of the MCA. Pr. Çekirge did this case on a flow model with only one FD Stent. During the treatment, he cited differences between the structures of the Pipeline vantage and the pipeline flex in the ability to modify the anatomy of the artery, which is one of the main facts, according to him, to have a good result in this type of case. There was a good discussion about the safety of this type of treatment and in which branch the FD should be positioned. As there is no consensus on the subject, we can see different strategies that was proposed by the faculty: stent assisted coil, endosacular devices, endosacular devise with stent and simple coiling.

• Further reading:

1) Piano, M. et al. Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging. J. Stroke Cerebrovasc. Dis. 31, 106760 (2022)

2) BhogalP,AlMatterM,Ba ̈znerH,etal.Flowdiversionforthetreat- ment of MCA bifurcation aneurysms: a single centre experience. Front Neurol 2017;8:20 CrossRef Medline

3) BhogalP,MartinezR,GansladtO,etal.Managementofunruptured saccular aneurysms of the M1 segment with flow diversion: a single centre experience. Clin Neuroradiol 2016 Dec 11. [Epub ahead of print] CrossRef Medline

4) Briganti F, Napoli M, Leone G, et al. Treatment of intracranial an- eurysms by flow diverter devices: long-term results from a single center. Eur J Radiol 2014;83:1683–90 CrossRef Medline

5) Caroff J, Neki H, Mihalea C, et al. Flow-diverter stents for the treat- ment of saccular middle cerebral artery bifurcation aneurysms. AJNR Am J Neuroradiol 2016;37:279 – 84 CrossRef Medline

6) IosifC,MounayerC,YavuzK,etal.Middlecerebralarterybifurca- tion aneurysms treated by extrasaccular flow diverters: midterm angiographic evolution and clinical outcome. AJNR Am J Neurora- diol 2017;38:310 –16 CrossRef Medline

7) F. Cagnazzo, D. Mantilla, P.-H. Lefevre, C. Dargazanli, G. Gascou and V. Costalat American Journal of Neuroradiology December 2017, 38 (12) 2289-2294