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Case series
Predictive score for complete occlusion of intracranial aneurysms treated by flow-diverter stents using machine learning
  1. Alexis Guédon1,2,
  2. Cédric Thépenier3,4,
  3. Eimad Shotar5,
  4. Joseph Gabrieli6,
  5. Bertrand Mathon7,8,
  6. Kévin Premat5,8,
  7. Stéphanie Lenck5,
  8. Vincent Degos8,9,
  9. Nader Sourour5,
  10. Frédéric Clarençon5,8
  1. 1 Biosurgical Research Lab (Carpentier Foundation), European Georges-Pompidou Hospital, INSERM UMR_S 1140, University of Paris, Paris, France
  2. 2 Department of Anatomy, University of Paris, Paris, France
  3. 3 French Armed Forces Biomedical Research Institute (IRBA), Brétigny-sur-Orge, France
  4. 4 Department of Experimental Neuropathology, Institut Pasteur, Paris, France
  5. 5 Department of Neuroradiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
  6. 6 Department of Neuroradiology, University of Padova Faculty of Medicine and Surgery, Padova, Veneto, Italy
  7. 7 Department of Neurosurgery, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
  8. 8 Sorbonne University, Paris, Île-de-France, France
  9. 9 Department of Neuro-anesthesiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
  1. Correspondence to Professor Frédéric Clarençon, Sorbonne Université, 75006 Paris, France; frederic.clarencon{at}


Background Complete occlusion of an intracranial aneurysm (IA) after the deployment of a flow-diverter stent is currently unpredictable. The aim of this study was to develop a predictive occlusion score based on pretreatment clinical and angiographic criteria.

Methods Consecutive patients with ≥6 months follow-up were included from 2008 to 2019 and retrospectively analyzed. Each IA was evaluated using the Raymond–Roy occlusion classification (RROC) and dichotomized as occluded (A) or residual (B/C); 80% of patients were randomly assigned to the training sample. Feature selection and binary outcome prediction relied on logistic regression and threshold maximizing class separation selected by a CART tree algorithm. The feature selection was addressed by a genetic algorithm selected from the 30 pretreatment available variables.

Results The study included 146 patients with 154 IAs. Feature selection yielded a combination of six variables with a good cross-validated accuracy on the test sample, a combination we labeled DIANES score (IA diameter, indication, parent artery diameter ratio, neck ratio, side-branch artery, and sex). A score of more than −6 maximized the ability to predict RROC=A with sensitivity of 87% (95% CI 79% to 95%) and specificity of 82% (95% CI 64% to 96%) in the training sample. Accuracy was 86% (95% CI 79% to 94%). In the test sample, sensitivity and specificity were 89% (95% CI 77% to 98%) and 60% (95% CI 33% to 86%), respectively. Accuracy was 81% (95% CI 69% to 91%).

Conclusion A score was developed as a grading scale for prediction of the final occlusion status of IAs treated with a flow-diverter stent.

  • Aneurysm
  • Angiography
  • Device
  • Flow Diverter
  • Stent

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  • Contributors Conception and design: AG, CT, FC. Acquisition of data: AG, ES, NS, FC. Analysis and interpretation of data: AG, CT, FC. Drafting the article: AG, CT, FC. Critical revision of the article: ES, JG, BM, KP, SL, VD. Review of submitted version of manuscript: AG, CT, FC. Approval of the final version of the manuscript on behalf of all authors: FC.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests FC reports conflict of interest with Medtronic, Guerbet, Balt Extrusion (payment for readings), Codman Neurovascular (core lab). NS is consultant for Medtronic, Balt Extrusion, Microvention, Stock/Stock Options: Medina. The other authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. The manuscript is not supported by industry.

  • Patient consent for publication Not required.

  • Ethics approval Approval of the institutional review board was obtained (CPP-Ile-de-France VI, Groupe Hospitalier Pitié-Salpêtrière, Pr Nathalie Brion, June 14th 2019); without patient informed consent required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.