Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms

Abstract

Background

The invention of flow diverting stents (FDS) is a novel milestone in the field of endovascular aneurysm therapy, promoting physiological healing of the vessel segment contrary to prior deconstructive treatment strategies, such as coiling. The effects of FDS are based on changes in flow patterns, segmental wall stabilization, and the growth of a neointima. Although flow diversion is already well established for cerebral aneurysms in proximal segments, peripheral locations remain challenging. Especially the middle cerebral artery (MCA) with its predominance of non-collateralized perforators and functional end arteries that supply the eloquent areas of the brain is of major concern.

Methods

The literature was reviewed for flow diversion of the MCA and antiplatelet therapy.

Results and Conclusion

Resulting from the special anatomical characteristics of the MCA, FDS implantation in this territory is completely different from the proximal vessel segments. Still, flow diversion represents an effective endovascular strategy, especially in otherwise non-accessible or sufficiently treatable lesions. However, the risk of ischemic adverse events might be increased. Special attention to the individual decision regarding device selection, antiplatelet regimen, and exact definition of the proximal and distal landing zone considering the jailed side branches is essential for a good angiographic and clinical outcome.

Key Points

• MCA aneurysms can be sufficiently treated by FDS.

• The anatomic and hemodynamic characteristics of the MCA result in an increased risk of thromboembolism.

• Individual device selection and antiplatelet regimen are essential for treatment success.

Citation Format

• Schüngel M, Wohlgemuth WA, Elolf E et al. Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms. Fortschr Röntgenstr 2024; DOI 10.1055/a-2343-0046

Zusammenfassung

Hintergrund

Die Einführung flussmodulierender Stents ist als neuer Meilenstein für die zerebrale Aneurysmatherapie zu betrachten. Anders als beispielsweise bei der Coil-Okklusion wird über die Veränderung der lokalen Hämodynamik, die Stabilisierung der erkrankten Gefäßwand und die Bildung einer neuen Intima der Aneurysmaverschluss schrittweise erzielt. Obgleich flussmodulierende Stents bereits für die Behandlung von proximalen hirnversorgenden Gefäßabschnitten etabliert sind, stellen periphere Segmente distal des Circulus Willisii eine Herausforderung dar. Insbesondere die Arteria cerebri media, welche zahlreiche nicht kollateralisierbare Perforatoren und für eloquente Hirnareale essenzielle Endarterien trägt, nimmt in diesem Zusammenhang eine besondere Stellung ein.

Methode

Es erfolgte die Literaturrecherche zu flussmodulierenden Stents für die Aneurysmatherapie der Arteria cerebri media mit besonderem Augenmerk auf der Thrombozytenaggregationshemmung in diesem Kontext.

Ergebnisse und Schlussfolgerung

Resultierend aus den anatomischen Besonderheiten der Arteria cerebri media unterscheidet sich die Implantation hämodynamisch aktiver Implantate wesentlich vom Einsatz in weiter proximal gelegenen Gefäßsegmenten. Trotz dessen stellt diese Therapieoption einen effektiven Behandlungsansatz für anderweitig nicht oder lediglich schwer behandelbare Aneurysmen in diesem Gefäßterritorium dar. Jedoch ist das Thromboembolierisiko vergleichsweise hoch. Besonderer Beachtung bedarf die Implantatarchitektur- und Oberfläche, die notwendige Thrombozytenaggregationshemmung und die genaue Definition der proximalen und distalen Landezone mit Verweis auf überlegte Seitenäste, um ein gutes hämodynamisches Ergebnis und klinisches Outcome zu ermöglichen.

Kernaussagen

• Aneurysmen der A. cerebri media können suffizient mittels flussmodulierender Stents behandelt werden.

• Die anatomischen und hämodynamischen Besonderheiten der Arteria cerebri media bedingen ein erhöhtes Ischämierisiko.

• Die sorgfältige Implantatauswahl und angepasste Thrombozytenaggregationshemmung sind wesentlich für den Behandlungserfolg.

Keywords

aneurysm - middle cerebral artery - antiplatelet therapy

Publication History

Received: 04 April 2024

Accepted after revision: 03 June 2024

Article published online:
08 July 2024

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