FLOW DIVERTERS FOR CERBERAL ANEURYSMS

Vipul Gupta

Artemis HospitalsGurgaonIndia

Endovascular mgt of aneurysms….

Issues..

Large and giant aneurysms

Fusiform/dissecting aneurysms

Blister aneurysms

Small dysplastic aneurysms

1917

pts.

451

patients

ISUIA Trial

Large, giant aneurysms

Classically - Surgery treatment of choice -Better occlusion, more permanent, mass effect

Endovascular – safer, issue of residual/recurrences; mass effect of coils

Stents

Flow modification

Intimal growth and healing

Change of angles

Flow modification/diversion-

Flow diversion with stents- single, overlapping

Further evolution – flow diverters (stents)

0

1

2

3

4

5

6

7

8

9

10

0 10 20 30 40 50 60 70 80 90 100

Flow index

Ineffective

(clotting)Ineffective

(free flow)

Effective flow

diversion and side

branch patencyOptimizing

flow diversion

A B

Cavernous aneurysms

26 year old,

Cranial nerve palsy

B

G

Large ICA aneurysms …

• Complete occlusion – 90 %, no recurrences

• Complication rate – 2-8 %

• Careful placement , avoid overlapping

devices, anti-platelet regime

Small Blister/dissecting…

Blister aneurysms (BA) are rare lesions characterized by a hemispherical shape and fragile walls

Surgical Options - Direct clipping, clipping plus wrapping, wrapping alone, clipping with Sundtencircling graft clips, encircling silicone clip application, primary suturing of ICA, vascular staple clip closure of ICA and trapping with or without extracranial-intracranial bypass

High risk of premature rupture during surgery, large lacerations

Endovascular- difficult to coil, friable, continued growth, stent needed (issues in SAH), single/overlapping

Classical blister aneurysm

34-year M, SAH

D E F

B CA B

B

C D

A

Blister Aneurysm

Our experience with FD vs non FDFD – 11 cases

Complete occlusion – 89% vs 71% i.f.o FD

Repeat treatment – none vs 11.7% i.f.o FD

Rebleed resulting in death – none vs 5.8% i.f.o FD

Submitted for publication

Small ICA aneurysms …

Dissections with blister

2-overlapping Enterprise stents

Posterior circulation aneurysms …

Distal bifurcation aneurysms

Intermediate Flow diverters (FRED junior)

Is it all easy ….

Progressive intraaneurysmalpartial thrombosis starts

8th

DAY POST COILING PRESENTED WITH VERTIGO AND HEADACHE

56 yr old,

ischaemic

stroke

Flow diverters … Major evolution of EVT of aneurysms

TOC for large/giant ICA aneurysms

Blister/small dysplastic aneurysms

Posterior circulation – more careful use

Evolving – distal aneurysms

Issues – cost, expertise, posterior ciruclationgiant aneurysms …

For more information on:

STROKE & NEUROVASCULAR INTERVENTIONS:

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Dr Vipul Gupta

Thank you ….