Quantitative assessment of parent vessel and distal intracranial hemodynamics following pipeline flow diversion

Abstract

Background Pipeline embolization devices (PEDs) are commonly used for endovascular treatment of cerebral aneurysms but can be associated with delayed ipsilateral intraparenchymal hemorrhage. Although intra-aneurysmal hemodynamic changes have been studied, parent vessel and intracranial hemodynamics after PED use are unknown. We examine the impact of flow diversion on parent artery and distal intracranial hemodynamics. Method Patients with internal carotid cerebral aneurysms treated with PED who had flow volume rate, flow velocities, pulsatility index, resistance index, Lindegaard ratio, and wall shear stress (WSS) obtained after treatment using quantitative magnetic resonance angiography were reviewed. Means were compared between ipsilateral and contralateral internal carotid artery (ICA) and middle cerebral artery (MCA) using paired t tests. Results A total of 18 patients were included. Mean flow volume rate was lower in the ipsilateral versus contralateral ICA ( p = 0.04) but tended to be higher in the ipsilateral versus contralateral MCA ( p = 0.08). Lindegaard ratio was higher ipsilateral to the PED in diastole ( p = 0.05). Although there was no significant difference in flow velocities, pulsatility or resistance indices, and WSS, the two cases in our cohort with hemorrhagic complications did display significant changes in MCA flows and MCA WSS. Conclusion PED placement appears to alter the elasticity of the stented ICA segment, with lower flows in the ipsilateral versus contralateral ICA. Conversely, MCA flows and MCA WSS are higher in the ipsilateral MCA among patients with hemorrhage after PED placement, suggesting the role of disrupted distal hemodynamics in delayed ipsilateral intraparenchymal hemorrhage.

Keywords: Cerebral aneurysm; flow diversion; intracranial hemodynamics; magnetic resonance angiography; pipeline embolization device.

Figure 1.

Ipsilateral versus contralateral flow volume rates. Flow is significantly lower in the internal carotid artery (ICA) but the trend is higher in the middle cerebral artery (MCA) after pipeline embolization device (PED) treatment. *indicates p ≤ 0.05. CI: confidence interval.

Figure 2.

Ipsilateral versus contralateral pulsatility index (PI) and resistance index (RI). (a) PI, RI are unchanged in the internal carotid artery (ICA); (b) but the trend is lower in the middle cerebral artery (MCA) after pipeline embolization device (PED) treatment. CI: confidence interval.

Figure 3.

Ipsilateral versus contralateral Lindegaard ratio. Lindegaard ratios are all higher ipsilateral to the pipeline embolization device (PED) when calculated using mean, systolic, and diastolic flow velocities. *indicates p ≤ 0.05. CI: confidence interval; ICA: internal carotid artery; MCA: middle cerebral artery.