Pipeline embolization of complex, wide-necked middle cerebral artery bifurcation aneurysms: A single-center experience

Abstract

Purpose: To evaluate the performance of Pipeline Embolization Device (PED) in complex, wide-necked middle cerebral artery (MCA) bifurcation aneurysms.

Methods: We performed a retrospective review of patients treated with PED for complex, wide-necked MCA bifurcation aneurysms between August 2016 and March 2021. In addition to demographic data, we collected aneurysmal neck width, dome-to-neck ratio, complications, and clinical and angiographic follow-up. The embolization degree of aneurysms was evaluated by O'Kelly-Marotta (OKM) grading scale, and the prognosis was assessed with the modified Rankin Scale (mRS).

Results: From August 2016 to March 2021, a total of 46 patients with 49 MCA bifurcation aneurysms in our center were enrolled, of whom all received PEDs successfully. The O'Kelly-Marotta (OKM) grading showed that post-procedure 15 patients (32.6%) were grade C, another 8 patients (17.4%) were grade D. Aneurysms with small remnant or complete occlusion were 50%, symptomatic ischemic events occurred in 3 (6.5%), and bleeding events in 1 (2.2%). 41 patients underwent a 6-month angiography follow-up, in which 7 patients (17.1%) remained OKM grade C and 30 patients (73.2%) achieved OKM grade D. Complete occlusion and small remnant aneurysms were up to 90.3%. 40 (97.6%) patients' mRS scores were 0, and 1 (2.4%) patient was 2. No new bleeding and ischemic events occurred during the 6-month.

Conclusions: The Pipeline Embolization Device provides a safe and effective treatment alternative for complex, wide-necked MCA aneurysms. A larger number with longer-term follow-up data is needed for further verification.

Keywords: Flow diverter; complex; pipeline embolization device; wide-necked middle cerebral artery aneurysms.

Figure 1.

A 59-year-old man who presented headache with finding aneurysm was treated in our center. (a and b) Right angiogram and three-dimensional reconstruction showing an MCA complex bifurcation aneurysm. (c, d, f) Left internal angiogram showing a wide-necked MCA aneurysm recanalized after treatment with coiling. (e) After six months, the aneurysm was completely occluded.

Figure 2.

A 53-year-old man who presented with an incidentally found aneurysm was treated in our center. (a and b) 3D rotational angiography and left internal angiogram showing a wide-necked complex MCA aneurysm. (c) Left internal angiogram showing a wide-necked MCA aneurysm recanalized after treatment with PED and coiling. (d) Post-procedure angiography showed partial occlusion of the aneurysm. (e) VASCO-CT shows that the stent adheres well. (f) After six months, the aneurysm was completely occluded.