The Combined Use of Intraluminal and Intrasaccular Flow Diversion for the Treatment of Intracranial Aneurysms: Report of 25 Cases

Abstract

Purpose: The Medina Embolic Device (MED) is a new intrasaccular device with promising early results. Previously we documented our initial experience of this device both alone and in combination with other devices including flow diverter stents (FDS). We sought to determine the effect of the MED + FDS strategy for the treatment of selected aneurysms.

Materials and methods: We performed a retrospective analysis of prospectively collected data to identify all patients with aneurysms treated using both the MED and intraluminal FDS. We present our technical success rate, early and mid-term angiographic follow-up, and clinical outcome data.

Results: We identified 25 non-consecutive patients. The treatment was staged in 9 patients and in a single session 16 patients. The average age was 61±12.8 years (range 40-82). The average fundus height was 11±3.6 mm and average fundus width was 10.1±3.4 mm. In the staged cohort (n=9) at delayed angiography (mean 10 mths) 8 aneurysms (89%) showed complete exclusion (mRRC 1) and in one patient there was a parent vessel occlusion. In the simultaneous cohort delayed angiography (n=10, mean 8.1 months) demonstrated complete occlusion (mRRC 1) in 6 aneurysms (60%), 3 neck remnants (mRRC 2) (30%) and 1 patient (10%) showed persistent aneurysmal filling (mRRC 3a). There were 5 complications with permanent morbidity (mRS >2) in two patients. There were no mortalities.

Conclusion: The MED can be successfully used in combination with intraluminal FDS and in selected aneurysms this may represent an alternative to FDS and adjunctive coiling.

Keywords: Intracranial aneurysm; Medina embolization device; flow diversion.

Fig. 1. A patient in their 30's with an unruptured incidental right PComA aneurysm that measured 9×5 mm (A). At the initial treatment two MED's were placed in the aneurysm sac and at the end of the procedure sub-total opacification of the aneurysm was seen (B). At initial follow-up (one month) there was a significant neck remnant and filling of the proximal fundus (C). At this stage a single p64 FDS was implanted (D). Follow-up three months after implantation of the FDS showed complete exclusion of the aneurysm from the circulation (mRRC 1) and mild, asymptomatic, in-stent stenosis (E) that spontaneously resolved on delayed angiography (F).

Fig. 2. A patient in their 70's with an incidental 9×12 mm para-ophthalmic aneurysm (A) was treated initially with a MED with a p64 FDS deployed during the same procedure (B). At the end of the procedure there was persistent filling of the aneurysm (C). Early follow-up angiography (two months post-procedure) showed a persistent neck remnant (D), which gradually decreased over time (E). At delayed angiography (eight months) there is complete exclusion of the aneurysm from the circulation (mRRC I) (F).

Fig. 3. A patient in their 70's with an incidental 8×8 mm of the supraclinoid ICA (A) was treated with the MED and a p64 FDS using a jailing technique. After the catheterisation of the aneurysm and the M1 segment (B) the p64 was partially deployed until it completely covered the neck of the aneurysm (C). Subsequently, three MED's were deployed in the aneurysm (D) and the p64 was fully deployed and detached. Angiography at the end of the procedure showed marked contrast stagnation within the aneurysm (E). Angiography performed seven months post-procedure demonstrated complete exclusion of the aneurysm from the circulation (mRRC 1) (F).