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Brain aneurysm and parent vessel remodeling after flow diversion treatment: a proposed modification for Cekirge-Saatci classification (mCSC)
  1. Ricardo A Hanel1,
  2. Gustavo M Cortez1,
  3. Demetrius Klee Lopes2,
  4. Isil Saatci3,
  5. H Saruhan Cekirge3,4
  1. 1Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
  2. 2Brain and Spine Institute, Advocate Aurora Health, Park Ridge, Illinois, USA
  3. 3Radiology Department, Koru Health Group, Ankara, Turkey
  4. 4Private Office, Saruhan Cekirge, Ankara, Turkey
  1. Correspondence to Dr Isil Saatci, Koru Health Group, Ankara, Turkey; isaatci{at}gmail.com

https://doi.org/10.1136/jnis-2022-019757

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    Endovascular therapy is the preferred treatment approach for managing ruptured intracranial aneurysms after studies demonstrated an overall safer profile than surgical clipping.1 Evolving and refining technology also settled neurointervention as the main approach for treating unruptured aneurysms worldwide, with few exceptions.2 3 A key element to attest to the impact and establish the efficacy of endovascular surgery is the development of universal scales to quantify aneurysm occlusion after treatment. Numerous classifications have been proposed to document aneurysm occlusion and guide patient surveillance imaging.4–6 The Raymond-Roy classification was originally developed to measure the degree of aneurysm occlusion after coiling and has been the preferred tool for assessing intervention outcomes.4

    The introduction of flow diverters (FDs) led to a significant paradigm shift.7 FDs primarily work by redirecting blood flow away from the aneurysm and providing scaffolding for endothelialization across the neck, which results in exclusion from circulation.8 The mechanism of parent vessel remodeling commonly evolves over weeks to months.8 It is not uncommon, however, that aneurysms with a side branch (coming from the dome or neck) or aneurysms involving a bifurcation take longer to occlude after flow diversion.9 This delay in occlusion results from the demand for blood flow generated by a pressure gradient between the parent vessel and branch.10

    Several classifications have been proposed to address the limitations of the Raymond-Roy classification in aneurysms treated with FDs.6 11 12 For the specific assessment of aneurysms treated with such stents, proposed grading scales have commonly taken into account aneurysm filling, concomitantly with either the degree of contrast stasis inside the aneurysm or parent artery status.6 11 12 Nonetheless, none of these factors has been demonstrated to be a reliable marker of aneurysm occlusion. Particular limitations of evaluating contrast stagnation include variable …

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    • Contributors All authors have substantially contributed to the conception and design of the study. RAH: contributed to data interpretation, planning, conception and design, manuscript preparation. GMC: contributed to data interpretation, conception and design, manuscript preparation. DKL: contributed to data interpretation, planning, conception and design, manuscript preparation. IS: contributed to data interpretation, planning, conception and design, manuscript preparation. HSC: contributed to data interpretation, planning, conception and design, manuscript preparation.

    • 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 RAH is a consultant for Medtronic, Stryker, Cerenovous, Microvention, Balt, Phenox, Rapid Medical, and Q'Apel. He is on the advisory board for MiVI, eLum, Three Rivers, Shape Medical and Corindus. Unrestricted research grant from NIH, Interline Endowment, Microvention, Stryker, CNX. Investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. Unrestricted research grant from NIH, Interline Endowment, Microvention, Stryker, CNX. Investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. GMC has no disclosures to report. DKL is consultant for Medtronic, Stryker, Asahi, Rapid.AI and QApel. Advisory Board: Q’Apel, Siemens, investor/stockholder for Three Rivers, Q’Apel, Vastrax, Synchron, Viz.AI, Methinks, Bendit, eLum, NVI. IS is a consultant and has proctorship agreements with Medtronic and MicroVention Inc. HSC is a consultant and has proctorship agreements with Medtronic and MicroVention Inc. Shareholder of Neuravention, Sychron Inc, Bend It Tech, Sim & Cure and Vesalio LLC.

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

    • 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.