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Is flow diversion the death of cerebral bypass and coiling/stent-assisted coiling for giant cavernous aneurysms? A critical review on comparative outcomes and ongoing clinical trials

Abstract

The classic surgical treatment for symptomatic giant aneurysms originating from the cavernous segment of the carotid artery has been either microsurgical direct clip-reconstruction or carotid occlusion followed by additional cerebral bypass for those patients who fail in a balloon test occlusion. Nevertheless the emergence of new endovascular techniques, especially flow-diverting devices, has promised to revolutionize the treatment of giant cavernous aneurysms, possibly avoiding major microsurgical operations. In this review the authors summarize the current “state-of-art” of treatment of giant cavernous aneurysms, comparing the overall outcomes, complications, morbidity and mortality rates of new flow-diverting devices in relation to traditional microsurgical series.

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Correspondence to Tobias A. Mattei.

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Comments

Paulo Henrique Pires de Aguiar; Sao Paolo, Brazil

The paper is well written, with many considerations regarding all options of intracavernous sinus aneurysm treatment. They classified in partial cavernous sinus aneurysm and pure cavernous sinus aneurysm treatment and performed a very interesting comparison between endovascular techniques and surgical techniques for the treatment of such aneurysms. The main point was the discussion about the complications of the flow divert devices, specially the physiopathological possibilities. In my opinion the second hypothesis showing a similar physiopathology of breakthrough is controversial, but it is mentioned in the literature .The conclusion is very important for further questions regarding the future use of flow divert devices. I mean that the Cordis Enterprise(TM) Self-expanding Intracranial Stent and Enterprise Stent Aneurysm Treatment Study shall bring new horizons for this very important topic.

Shokei Yamada, Loma Linda, USA

According to the authors, this article is intended to provide general neurosurgeons with the new technology of intravascular intervention. The emphasis is placed on intracavernous aneurysms, especially those with extra sinus extension into the intradural space. To circumvent difficulties with obliterating these aneurysms by clipping and coiling, they introduce flow-diverting devices, Pipeline Embolization Device (PED) and SILK system.

First, the PED is a new endovascular stent designed to exclude aneurysms from the parent cerebrovasculature. The technology of this stand-alone device with self-expanding mesh tube was initially thought to be highly effective in anatomically reconstructing large segmental vascular defects, and secondarily occluding wide-necked, giant aneurysms or fusiform aneurysms. Yet, the statistical information for successes is still limited.

Second, the SILK stent utilizes a braided mesh cylinder with flared ends, designed to provide 35–55 % metal coverage. Although this technology was claimed to be a valuable tool in the endovascular treatment of cavernous sinus aneurysms, only unruptured aneurysms are the target of this treatment. No statistical analysis of large series to evaluate procedural outcomes of these devices is available. The authors’ concern is rather the morbidity associated with the application of these new devices. MARCOPOLO studies by British groups were mentioned without referring to statistics.

The discussion section includes valuable pathophysiological analysis of the benefit and complications involved in the new technology. Despite their enthusiastic selection of an important subject, "the treatment of intracavernous sinus aneurysms with extracavernous extension,” the authors have not reached any conclusion as to which procedure they would advise for readers to select between the traditional surgical treatment (i.e., the aneurysm clipping or EC-IC bypass procedure) and the new intravascular procedures.

While these devices potentially show promise, further studies with hopefully, prospective, randomized controlled trials to support their use will occur. Currently, the literature does not support the use of these devices and they would still fall under the category of "investigational.”

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Mattei, T.A., Ferrell, A.S. & Britz, G.W. Is flow diversion the death of cerebral bypass and coiling/stent-assisted coiling for giant cavernous aneurysms? A critical review on comparative outcomes and ongoing clinical trials. Neurosurg Rev 36, 505–512 (2013). https://doi.org/10.1007/s10143-013-0459-9

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  • DOI: https://doi.org/10.1007/s10143-013-0459-9

Keywords

  • Flow-diverting devices
  • Giant intracranial aneurysms
  • Cavernous sinus aneurysms
  • Pipeline device
  • Silk stent
  • Clinical trials