Flow diverter stent for the treatment of ruptured distal anterior cerebral artery: A retrospective multicenter analysis from CRETA registry

Abstract

BackgroundData on off-label use of flow diverter for ruptured distal anterior cerebral artery aneurysms (rDACAAs) are limited. The purpose of the present study is to evaluate the efficacy and safety of flow diversion for rDACAAs in a large multicenter cohort.MethodsA retrospective observational study on consecutive patients who were treated with flow diversion for rDACAAs at 8 centers in 4 countries was performed. Primary outcome was the occlusion rate of the target aneurysm at the last radiological follow-up. Secondary outcomes included good clinical outcome, retreatment, technical success, procedure-related complications, radiological outcome of the covered branches and mortality rate.ResultsA total of 21 patients with 21 rDACAAs were treated between January 2017 and December 2024. Thirteen patients were women (61.9%) and the median age was 54 years (IQR 46-66). The most common etiology was saccular (71.4%), followed by dissecting (23.8%) and mycotic (4.8%). In all patients a single stent was successful deployed. Median imaging follow-up was 9 (7-12) months. At last follow-up adequate occlusion was 95.2%. Symptomatic thromboembolic or hemorrhagic complications occurred in 9.5% of patients. Seventeen patients (81%) had good clinical outcome (mRS 0-2) with mortality rate of 9.5%. In-stent stenosis occurred in one case that was conservatively managed without major concerns.ConclusionsFlow diversion is feasible as a potential treatment strategy for acutely ruptured aneurysms arising from distal anterior cerebral artery. Flow diverter may represent a valid option whenever other treatments are considered challenging or high risk.

Keywords: Ruptured aneurysm; distal anterior cerebral aneurysm; flow diverter stent.

Figure 1.

Enrollment flow chart. DACA, distal anterior cerebral artery. SAH, subarachnoid hemorrhage.

Figure 2.

(A): coronal turbo FLAIR showing edema of cingulate gyrus and corpus callosum associated with adjacent flow void suggesting distal aneurysm of the anterior cerebral artery. (B): SWI sequence subarachnoid hemorrhage within the sulci of the cerebral convexities bilaterally. (D): DSA showing mycotic aneurysm located at the bifurcation of the pericallosal and callosomarginal arteries. (E): DSA performed after coil embolization identifies partial thrombosis of pericallosal artery that was successfully treated with tirofiban. (F): DSA 2 days after coiling treatment shows recanalization and enlargement of aneurysmal sac. (G): deployment of flow-diverter stent (Silk Vista Baby 2.5 × 15 mm). (C): 8 months post-treatment MRI showing complete occlusion of the aneurysm without early and late ischemic events.

Figure 3.

(A): ct image showing an intraparenchymal hematoma in the fronto-mesial region associated with a minimal adjacent subarachnoid hemorrhage. (B) and (C): DSA before and after embolization with coils of a saccular aneurysm located at the bifurcation of the pericallosal and callosomarginal arteries. (D): DSA 4 days after the hemorrhage showing partial recanalization of the aneurysmal neck. (E) and (F): Endovascular treatment with placement of a Silk Vista Baby 2.5 × 15 mm flow-diverter stent. (G) and (H): 6 months post-treatment DSA showing complete occlusion of the aneurysm.