Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging



      In this study, the authors retrospectively evaluated the effectiveness and the safety of non-surgical middle cerebral artery (MCA) aneurysms treated via the implantation of a flow diverter device (FDD).


      Clinical, procedural and follow-up data were analyzed in order to evaluate the safety and effectiveness of the treatment with the FDD in complex MCA aneurysms. Safety was assessed recording (intra-procedural, peri-procedural and delayed) complications in order to determine the morbidity and mortality rates. Functional outcome was evaluated with modified Rankin Scale (mRS) prior and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded.


      47 patients (21 males; 26 females) with MCA aneurysms were treated with FDD. 7 were ruptured. 21 aneurysms were saccular, 19 dissecting, 3 fusiform, 2 blood blister-like and 2 were pseudo-aneurysms. 14 aneurysms were small, 23 large and 10 giant, with a mean size of 15.3 mm. 8 aneurysms were recurrent (Raymond-Roy class III): 2 patients had an aneurysmal sac recanalization after being treated with simple coiling and 6 after being treated with microsurgical clipping. In 4 cases (8.5%), more than one FDD was telescopically positioned in order to treat the aneurysm, for a total of 54 FDDs used.
      The overall mortality rate was 2.1% (1/47) and the overall morbidity rate was 8.6% (4/47). Midterm neuroimaging follow-ups showed the complete occlusion of the aneurysm in 63% cases, which became 91% at the end of the follow-up.


      FDD is a safe and effective tool that can be used in the treatment of complex MCA aneurysms, where conventional neurosurgical treatments can be challenging or ineffective.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Alreshidi M.
        • Cote D.J.
        • Dasenbrock H.H.
        • et al.
        Coiling versus microsurgical clipping in the treatment of unruptured middle cerebral artery aneurysms: a meta-analysis.
        Neurosurgery. 2018; 83: 879-889
        • Zaidat O.O.
        • Castonguay A.C.
        • Teleb M.S.
        • et al.
        Middle cerebral artery aneurysm endovascular and surgical therapies.
        Neurosurg Clin N Am. 2014; 25: 455-469
        • Zanaty M.
        • Chalouhi N.
        • Tjoumakaris S.I.
        • Gonzalez L.F.
        • Rosenwasser R.
        • Jabbour P.
        Flow diversion for complex middle cerebral artery aneurysms.
        Neuroradiology. 2014; 56: 381-387
        • Mortimer A.M.
        • Bradley M.D.
        • Mews P.
        • Molyneux A.J.
        • Renowden S.A.
        Endovascular treatment of 300 consecutive middle cerebral artery aneurysms: clinical and radiologic outcomes.
        Am J Neuroradiol. 2014; 35: 706-714
        • Rodríguez-Hernández A.
        • Sughrue M.E.
        • Akhavan S.
        • Habdank-Kolaczkowski J.
        • Lawton M.T.
        Current management of middle cerebral artery aneurysms.
        Neurosurgery. 2013; 72: 415-427
        • da Silva Júnior N.R.
        • Trivelato F.P.
        • Nakiri G.S.
        • et al.
        Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping.
        J Cerebrovasc Endovasc Neurosurg. 2021; 23: 221-232
        • Rouchaud A.
        • Brinjikji W.
        • Cloft H.J.
        • Kallmes D.F.
        Endovascular treatment of ruptured blister-like aneurysms: a systematic review and meta-analysis with focus on deconstructive versus reconstructive and flow-diverter treatments.
        Am J Neuroradiol. 2015; 36: 2331-2339
        • Barletta E.
        • Ricci R.
        • Silva R.G.
        • et al.
        Fusiform aneurysms: a review from its pathogenesis to treatment options.
        Surg Neurol Int. 2018; 9: 189
        • Lozupone E.
        • Piano M.
        • Valvassori L.
        • et al.
        Flow diverter devices in ruptured intracranial aneurysms: a single-center experience.
        J Neurosurg. 2018; 128: 1037-1043
        • Piano M.
        • Valvassori L.
        • Lozupone E.
        • et al.
        FRED Italian registry: a multicenter experience with the flow re-direction endoluminal device for intracranial aneurysms.
        J Neurosurg. 2019; 10 (Published online May): 1-8
        • Piano M.
        • Lozupone E.
        • Sgoifo A.
        • et al.
        Long-term follow-up of the Derivo® embolization device (DED®) for intracranial aneurysms: the Italian multicentric registry.
        J Neurosurg Sci. 2021; 65: 361-368
        • Brinjikji W.
        • Piano M.
        • Fang S.
        • et al.
        Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion.
        J Neurosurg. 2016; 125: 120-127
        • Lozupone E.
        • Garignano G.
        • D'Argento F.
        • et al.
        A revised stent-retriever anchor technique to obtain the distal access through a large or giant aneurysm.
        Vessel Plus. 2021; (Published online)
        • Piano M.
        • Valvassori L.
        • Quilici L.
        • Pero G.
        • Boccardi E.
        Midterm and long-term follow-up of cerebral aneurysms treated with flow diverter devices: a single-center experience.
        J Neurosurg. 2013; 118: 408-416
        • Lin N.
        • Lanzino G.
        • Lopes D.K.
        • et al.
        Treatment of distal anterior circulation aneurysms with the pipeline embolization device: a US multicenter experience.
        Neurosurgery. 2016; 79: 14-22
        • Bhogal P.
        • AlMatter M.
        • Bäzner H.
        • Ganslandt O.
        • Henkes H.
        • Aguilar Pérez M.
        Flow diversion for the treatment of MCA bifurcation aneurysms – a single centre experience.
        Front Neurol. 2017; 8
        • Briganti F.
        • Delehaye L.
        • Leone G.
        • et al.
        Flow diverter device for the treatment of small middle cerebral artery aneurysms.
        J NeuroInterventional Surg. 2016; 8: 287-294
        • Caroff J.
        • Neki H.
        • Mihalea C.
        • et al.
        Flow-diverter stents for the treatment of saccular middle cerebral artery bifurcation aneurysms.
        Am J Neuroradiol. 2016; 37: 279-284
        • Cimflova P.
        • Özlük E.
        • Korkmazer B.
        • et al.
        Long-term safety and efficacy of distal aneurysm treatment with flow diversion in the M2 segment of the middle cerebral artery and beyond.
        J NeuroInterv Surg. 2021; 13: 631-636
        • De Vries J.
        • Boogaarts J.
        • Van Norden A.
        • Wakhloo A.K.
        New generation of flow diverter (Surpass) for unruptured intracranial aneurysms: a prospective single-center study in 37 patients.
        Stroke. 2013; 44: 1567-1577
        • Diaz O.M.
        • Rangel-Castilla L.
        • Barber S.
        • Mayo R.C.
        • Klucznik R.
        • Zhang Y.J.
        Middle cerebral artery aneurysms: a single-center series comparing endovascular and surgical treatment.
        World Neurosurg. 2014; 81: 322-329
        • Feng Z.
        • Li Q.
        • Zhao R.
        • et al.
        Endovascular treatment of middle cerebral artery aneurysm with the LVIS junior stent.
        J Stroke Cerebrovasc Dis. 2015; 24: 1357-1362
        • Iosif C.
        • Mounayer C.
        • Yavuz K.
        • et al.
        Middle cerebral artery bifurcation aneurysms treated by extrasaccular flow diverters: midterm angiographic evolution and clinical outcome.
        Am J Neuroradiol. 2017; 38: 310-316
        • Saleme S.
        • Iosif C.
        • Ponomarjova S.
        • et al.
        Flow-diverting stents for intracranial bifurcation aneurysm treatment.
        Neurosurgery. 2014; 75: 623-631
        • Topcuoglu O.M.
        • Akgul E.
        • Daglioglu E.
        • et al.
        Flow diversion in middle cerebral artery aneurysms: is it really an all-purpose treatment?.
        World Neurosurg. 2016; 87: 317-327
        • Yavuz K.
        • Geyik S.
        • Saatci I.
        • Cekirge H.S.
        Endovascular treatment of middle cerebral artery aneurysms with flow modification with the use of the pipeline embolization device.
        Am J Neuroradiol. 2014; 35: 529-535
        • Möhlenbruch M.A.
        • Kizilkilic O.
        • Killer-Oberpfalzer M.
        • et al.
        Multicenter experience with FRED Jr flow re-direction endoluminal device for intracranial aneurysms in small arteries.
        Am J Neuroradiol. 2017; 38: 1959-1965
        • Gawlitza M.
        • Januel A.C.
        • Tall P.
        • Bonneville F.
        • Cognard C.
        Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: a single-center series with special emphasis on covered cortical branches and perforating arteries.
        J NeuroInterv Surg. 2016; 8: 481-487
        • Cagnazzo F.
        • Mantilla D.
        • Lefevre P.H.
        • Dargazanli C.
        • Gascou G.
        • Costalat V.
        Treatment of middle cerebral artery aneurysms with flow-diverter stents: a systematic review and meta-analysis.
        Am J Neuroradiol. 2017; 38: 2289-2294
        • Roy D.
        • Milot G.
        • Raymond J.
        Endovascular treatment of unruptured aneurysms.
        Stroke. 2001; 32: 1998-2004
        • Wiebers D.O.
        Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment.
        Lancet. 2003; 362 (9378): 103-110
        • Wiebers D.O.
        • Piepgras D.G.
        • Thielen K.
        Unruptured intracranial aneurysms – risk of rupture and risks of surgical intervention.
        N Engl J Med. 1998; 339: 1725-1733
        • Lv X.
        • Yang H.
        • Liu P.
        • Li Y.
        Flow-diverter devices in the treatment of intracranial aneurysms: a meta-analysis and systematic review.
        Neuroradiol J. 2016; 29: 66-71
        • Wang F.
        • Chen X.
        • Wang Y.
        • et al.
        Stent-assisted coiling and balloon-assisted coiling in the management of intracranial aneurysms: a systematic review & meta-analysis.
        J Neurol Sci. 2016; 364: 160-166
        • Toccaceli G.
        • Diana F.
        • Cagnazzo F.
        • et al.
        Microsurgical clipping compared with new and most advanced endovascular techniques in the treatment of unruptured middle cerebral artery aneurysms: a meta-analysis in the modern era.
        World Neurosurg. 2020; 137 (e1): 451-464
        • O'Connor S.A.
        • Hulot J.S.
        • Silvain J.
        • Cayla G.
        • Montalescot G.
        • Collet J.P.
        Pharmacogenetics of clopidogrel.
        Curr Pharm Des. 2012; 18: 5309-5327
        • Cattaneo M.
        Aspirin and clopidogrel: efficacy, safety, and the issue of drug resistance.
        Arterioscler Thromb Vasc Biol. 2004; 24: 1980-1987
        • Ravindran K.
        • Casabella A.M.
        • Cebral J.
        • Brinjikji W.
        • Kallmes D.F.
        • Kadirvel R.
        Mechanism of action and biology of flow diverters in the treatment of intracranial aneurysms.
        Neurosurgery. 2020; 86 (Supplement_1): S13-S19
        • Kiselev R.
        • Orlov K.
        • Dubovoy A.
        • et al.
        Flow diversion versus parent artery occlusion with bypass in the treatment of complex intracranial aneurysms: immediate and short- term outcomes of the randomized trial.
        Clin Neurol Neurosurg. 2018;