From the Guidelines
Actively enlarging brain aneurysms are not an absolute contraindication to flow diverting stent placement, and in certain cases, they may be specifically indicated. The use of flow diverters in such cases is based on their ability to address the underlying vascular pathology by redirecting blood flow away from the aneurysm sac while maintaining perfusion to normal branches 1. Key considerations for the placement of a flow-diverting stent in an actively enlarging intracranial aneurysm include:
- The need for dual antiplatelet therapy, typically aspirin and clopidogrel, for a period before the procedure to minimize the risk of thrombogenicity, as highlighted in the guidelines for the management of patients with aneurysmal subarachnoid hemorrhage 1.
- The importance of platelet function testing to ensure an adequate response to antiplatelet therapy.
- The risk of rupture during or after the procedure, particularly if the aneurysm is symptomatic or showing signs of instability, which may necessitate more immediate treatments like coiling or surgical clipping.
- The decision to use flow diversion should be highly individualized, taking into account aneurysm location, morphology, patient-specific factors, and the experience of the neurointerventional team, as these devices work gradually over weeks to months to achieve complete aneurysm occlusion 1. Given the information provided in the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage, the placement of a flow-diverting stent is not contraindicated in an actively enlarging intracranial aneurysm, but rather should be considered as part of a comprehensive treatment strategy 1.
From the Research
Placement of Flow-Diverting Stent in Actively Enlarging Intracranial Aneurysm
- The provided studies do not directly address the contraindication of flow-diverting stent placement in an actively enlarging intracranial aneurysm 2, 3, 4, 5, 6.
- However, the studies discuss the use of flow-diverting stents in the treatment of complex intracranial aneurysms, including giant, wide-necked, or fusiform aneurysms 2, 3, 4.
- The studies also highlight the potential risks and complications associated with flow-diverting stent placement, such as vessel rupture or perforation, in-stent thrombosis, perforator occlusion, procedural and delayed hemorrhages, and perianeurysmal edema 2, 4, 6.
- There is limited information on the specific scenario of an actively enlarging intracranial aneurysm, and the studies do not provide clear guidance on the contraindication of flow-diverting stent placement in this context 2, 3, 4, 5, 6.
Key Findings
- Flow-diverting stents have revolutionized the treatment of complex intracranial aneurysms, offering a new standard of care 2.
- The Pipeline flow-diverting stent has shown promising results in the treatment of wide-neck aneurysms, with a high occlusion rate at mid-term follow-up 4.
- The use of flow-diverting stents in patients on concurrent oral anticoagulation may carry increased risks and decreased efficacy 6.
- Further studies are needed to evaluate the safety and efficacy of flow-diverting stent placement in various clinical scenarios, including actively enlarging intracranial aneurysms 3, 5.