Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Abstract

Flow diversion (FD) is a novel endovascular technique based on the profound alteration of cerebrovascular hemodynamics, which emerged as a promising minimally invasive therapy for intracranial aneurysms. However, delayed post-procedural stroke remains an unexplained concern. A consistent follow-up-regimen has not yet been defined, but is required urgently to clarify the underlying cause of delayed ischemia. In the last two years, 223 patients were treated with six different FD devices in our center. We identified subacute, FD-induced segmental vasospasm (SV) in 36 patients as a yet unknown, delayed-type reaction potentially compromising brain perfusion to a critical level. Furthermore, 86% of all patients revealed significant SV approximately four weeks after treatment. In addition, 56% had SV with 25% stenosis, and 80% had additional neointimal hyperplasia. Only 13% exhibited SV-related high-grade stenosis. One of those suffered stroke due to prolonged SV, requiring neurocritical care and repeated intra-arterial (i.a.) biochemical angioplasty for seven days to prevent territorial infarction. Five patients suffered newly manifested, transient hemicrania accompanying a compensatorily increased ipsilateral leptomeningeal perfusion. One treated vessel obliterated permanently. Hence, FD-induced SV is a frequent vascular reaction after FD treatment, potentially causing symptomatic ischemia or even stroke, approximately one month post procedure. A specifically early follow-up-strategy must be applied to identify patients at risk for ischemia, requiring intensified monitoring and potentially anti-vasospastic treatment.

Endovascular Treatment of Intracranial Aneurysms in Small Peripheral Vessel Segments—Efficacy and Intermediate Follow-Up Results of Flow Diversion With the Silk Vista Baby Low-Profile Flow Diverter

“…Two patients suffered from hemodynamically relevant vasospasm manifesting between 1 and 3 weeks after endovascular treatment, a phenomenon that we reported earlier (13).…”

A Fully Automated Method for Segmenting Arteries and Quantifying Vessel Radii on Magnetic Resonance Angiography Images of Varying Projection Thickness

“…Some examples include moyamoya, atherosclerosis, radiation-induced arteriopathy, autoimmune vasculitis, and even chronic vascular disorders such as hypertension. It can aid in the automated evaluation of cerebral vasospasm after aneurysm treatment where the magnitude and pattern of vascular injury are variable in each patient (Schob et al, 2019). Another example is the evaluation of complex arteriovenous shunts, where the quantification of lesion size, location, and pattern is highly rater-dependent (Geibprasert et al, 2010).…”

Balloon-assisted coiling of intracranial aneurysms using the Eclipse 2L double lumen balloon

“…1 The balloon remodeling technique enables operators to treat aneurysms with less favorable dome-to-neck ratios, without the potential drawbacks of implantable assistive devices. 2 The safety and efficacy of balloon remodeling have been extensively documented in both retrospective and prospective studies. 1…”