Flow-Diversion Treatment for Unruptured ICA Bifurcation Aneurysms with Unfavorable Morphology for Coiling

Few reports described flow diversion for ICA bifurcation aneurysms. Our aim was to provide further insight into flow diversion for ICA bifurcation aneurysms difficult to treat with other strategies.

Consecutive patients receiving flow diverters for unruptured ICA bifurcation aneurysms were collected. Aneurysm occlusion (O'Kelly-Marotta grading scale) and clinical outcomes were evaluated.

Twenty saccular ICA bifurcation aneurysms were treated with the Pipeline Embolization Device deployed from the M1 to the ICA, covering the aneurysm and the A1 segment. All patients presented with an angiographic visualized contralateral flow from the anterior communicating artery. Mean aneurysm size was 6.5 (SD, 3.2) mm (range, 4.5-20 mm). All lesions had an unfavorable dome-to-neck ratio (mean/median, 1.6/1.6; range, 0.8-2.8; interquartile range = 0.5) or aspect ratio for coiling (mean/median = 1.5/1.55; range, 0.8-2.5; interquartile range = 0.6). One was a very large aneurysm (20 mm). Nineteen medium-sized lesions were completely occluded during the angiographic follow-up (13 months). No cases of aneurysm rupture or retreatment were reported. No adverse events were described. Aneurysm occlusion was associated with the asymptomatic flow modification of the covered A1 that was occluded and contralaterally filled among 10 patients (50%), narrowed among 9 patients (45%), and unchanged in 1 subject (5%). There was no difference in the mean initial diameter of the occluded (2.1 [SD 0.4] mm; range, 1.6-3 mm) and narrowed (2 [SD, 0.2] mm; range, 1.7-2.6 mm) A1 segments.

Medium-sized unruptured ICA bifurcation aneurysms with unfavorable morphology for coiling can be treated with M1 ICA flow diversion. Aneurysm occlusion is associated with flow modifications of the covered A1 that seems safe in the presence of a favorable collateral anatomy through the anterior communicating artery complex.