Ruptured Intracranial Aneurysms Treated with the Pipeline Embolization Device: A Systematic Review and Pooled Analysis of Individual Patient Data

Abstract

Background: The Pipeline Embolization Device (PED) is a flow-diverting stent for the treatment of intracranial aneurysms and is used off-label for a subset of ruptured aneurysms not amenable to traditional treatment.

Purpose: Our aim was to evaluate the safety and efficacy of the PED for treatment of ruptured intracranial aneurysms.

Data sources: A systematic review of the MEDLINE, EMBASE, and Scopus data bases from January 2011 to March 2020 was performed for articles reporting treatment of ruptured intracranial aneurysms with the PED.

Study selection: A total of 12 studies comprising 145 patients with 145 treated aneurysms were included for analysis.

Data analysis: Individual patient data were collected. Nonparametric tests were used to compare differences among patients. Logistic regression was used to determine an association with outcome variables.

Data synthesis: Mean aneurysm size was 5.9 mm, and most were blister (51.0%) or dissecting (26.9%) in morphology. Three (2.1%) aneurysms reruptured following PED placement. Univariate logistic regression identified larger aneurysm size as a significant predictor of aneurysm rerupture (P = .008). Of patients with radiographic follow-up, 87.5% had complete aneurysm occlusion. Symptomatic neurologic complications occurred in 16.5%.

Limitations: Analysis was limited by the quality of the included data, most of which were from small case series representing class III medical evidence. No study assessed outcome in a blinded or independently adjudicated manner.

Conclusions: Most ruptured aneurysms treated with the PED were blister or dissecting aneurysms. Treatment was associated with a rerupture rate of 2.1% and a complete occlusion rate of 87.5%.

FIG 1.

Flow diagram describing the selection process by which studies were included in the analysis of treatment of ruptured intracranial aneurysms with the Pipeline Embolization Device.

FIG 2.

Sample case of a ruptured dissecting aneurysm of the left vertebral artery treated with placement of the PED. A, CT of the head demonstrates subarachnoid hemorrhage consistent with aneurysm rupture. Note the large amount of left-sided posterior fossa SAH. B, 3D rotational angiography of the left vertebral artery shows the dissecting aneurysm (arrow). C, Left vertebral artery angiogram shows the dissecting aneurysm (arrow). C, Left vertebral artery angiogram demonstrates contrast stasis in the dissecting aneurysm (arrow) following PED placement.