Pipeline embolization of proximal middle cerebral artery aneurysms: A multicenter cohort study

Abstract

Background and purpose Flow diversion of aneurysms located in the M1 segment and middle cerebral artery bifurcation with Pipeline embolization device is sometimes performed, but further study is needed to support its regular use in aneurysm treatment. Here, we report measures of safety and efficacy for Pipeline embolization in the proximal middle cerebral artery in a multi-center cohort. Materials and methods Clinical and angiographic data of eligible patients were retrospectively obtained from participating centers and assessed for key clinical and angiographic outcomes. Additional details were extracted for patients with complications. Results In our multi-center cohort, complete aneurysm occlusion was achieved in 71% (17/24) of treated aneurysms. There were no deaths or disabling strokes, but non-disabling ischemic strokes occurred in 8% (2/24) of patients. For aneurysms in the M1 segment, complete aneurysm occlusion was observed in 75% (12/16) of aneurysms, aneurysm volume reduction was observed in 100% (16/16) of aneurysms, and non-disabling ischemic strokes occurred in 13% (2/16) of patients. For aneurysms at the middle cerebral artery bifurcation, complete aneurysm occlusion was observed in 63% (5/8) of aneurysms, aneurysm volume reduction occurred in 88% (7/8) of aneurysms, and ischemic or hemorrhagic complications occurred in 0% (0/8) of patients. Conclusion Pipeline embolization of cerebral aneurysms in the M1 segment and middle cerebral artery bifurcation demonstrated a 71% rate of complete aneurysm occlusion. There were no deaths or disabling strokes, but there was an 8% rate of non-disabling ischemic strokes.

Flow-diverter stents in intracranial aneurysm treatment: impact on covered cerebral artery branches

“…New complications arose in 1.6% of patients (95% CI: 0.4–3.6%; I 2 , 41.2%) with FDSs covering OA 9 , 15 , 18 , 19 , 24 , 26 , 34 , 36 – 38 , 51 , 65 , after excluding a heterogeneous study conducted by Rouchaud et al 23 . The data indicated a relatively higher risk among patients managed with FDSs covering MCA-M2 12 , 27 , 30 , 32 , 35 , 46 , 60 , 63 (rate, 2.6%; 95% CI: 0.2–6.5%; I 2 , 27.7%). Sensitivity and subgroup analyses identified that the source of heterogeneity was primarily a European study by Caroff et al 27 .…”

“…Among 50 studies 9 – 19 , 22 , 23 , 25 – 35 , 37 – 47 , 49 , 50 , 52 – 63 , 65 involving 3100 patients, the overall obliteration rate was 77.5% (95% CI: 74.0–80.9%; I 2 , 69.8%; Table S3, Supplemental Digital Content 2, http://links.lww.com/JS9/B226 , Figure S2, Supplemental Digital Content 2, http://links.lww.com/JS9/B226 ). Subgroup analyses indicated a high obliteration rate regardless of the specific branches covered by FDSs (Fig.…”

“…The pooled results showed indicated relatively low rates of occlusion/narrowing for OA 9 , 15 , 18 – 20 , 24 , 26 , 31 , 34 , 36 – 38 , 48 , 53 , 65 (rate, 11.8%; 95% CI: 8.8–15.1%; I 2 , 45.9%), AChoA 17 , 20 – 22 , 24 , 31 , 36 , 37 , 48 , 53 (rate, 0.5%; 95% CI: 0.0–2.9%; I 2 , 22.5%) and PICA 39 , 42 , 47 , 51 , 58 (rate, 6.8%; 95% CI: 1.5–14.5%; I 2 , 23.2%). In contrast, higher rates of occlusion or narrowing were observed for PComA 13 , 24 , 28 , 31 , 33 , 36 , 37 , 41 , 43 , 45 , 48 , 51 , 53 , 56 , 59 , 62 (rate, 44.3%; 95% CI: 34.2–54.6%; I 2 , 73.8%), ACA 31 , 37 , 47 , 51 , 53 , 54 , 62 , 65 (rate, 66.6%; 95% CI: 45.1–85.3%; I 2 , 85.0%) and MCA-M2 12 , 27 , 30 , 32 , 35 , 46 , 55 , 60 , 63 (rate, 39.2%; 95% CI: 24.5–54.7%; I 2 , 81.6%). Subgroup analysis reduced the large heterogeneity for...…”

“…However, a subgroup analysis could not be conducted due to the variability in antiplatelet regimens among the included studies. Several studies 9 , 10 , 12 , 14 , 20 , 22 , 27 , 31 , 35 , 38 , 45 , 52 , 56 , 58 , 60 , 62 , 63 have reported symptomatic thrombotic events of in-stent thrombosis or branch occlusion/narrowing caused by the inappropriate use of antiplatelets; however, several of the included studies did not elaborate on this, so we could not evaluate this association accurately. Additionally, branch occlusion may be observed in patients with in-stent thrombosis; however, these cases were not classified in our study.…”

Flow diversion for unruptured fusiform aneurysms of the proximal middle cerebral artery

“…In a meta-analysis focused on flow diversion for MCA aneurysms, Cagnazzo et al ( 15 ) reported a thromboembolic complication rate of 16.3%, with symptomatic stroke related to jailed branch occlusion and slow flow occurring in ~5% of cases. In another study by Lauzier et al ( 16 ), which involved a multicenter cohort, pipeline embolization was used for proximal MCA aneurysms. Although there were no deaths or disabling strokes, there was still an 8% rate of non-disabling ischemic strokes observed.…”