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Flow diversion for the treatment of intracranial bifurcation aneurysms: a systematic review and meta-analysis
  1. Ahmed Kashkoush1,
  2. Mohamed Ehab El-Abtah2,
  3. Jordan C Petitt2,
  4. Gregory Glauser1,
  5. Robert Winkelman1,
  6. Rebecca L Achey1,
  7. Mark Davison1,
  8. Mohammad A Abdulrazzak3,4,
  9. Shazam M Hussain3,4,
  10. Gabor Toth3,4,
  11. Mark Bain1,3,
  12. Nina Moore1,3
  1. 1Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
  2. 2Case Western Reserve University School of Medicine, Cleveland, OH, USA
  3. 3Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
  4. 4Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
  1. Correspondence to Dr Nina Moore, Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States of America; mooren4{at}


Background Flow diversion (FD: flow diversion, flow diverter) is an endovascular treatment for many intracranial aneurysm types; however, limited reports have explored the use of FDs in bifurcation aneurysm management. We analyzed the safety and efficacy of FD for the management of intracranial bifurcation aneurysms.

Methods A systematic review identified original research articles that used FD for treating intracranial bifurcation aneurysms. Articles with >4 patients that reported outcomes on the use of FDs for the management of bifurcation aneurysms along the anterior communicating artery (AComA), internal carotid artery terminus (ICAt), basilar apex (BA), or middle cerebral artery bifurcation (MCAb) were included. Meta-analysis was performed using a random effects model.

Results 19 studies were included with 522 patients harboring 534 bifurcation aneurysms (mean size 9 mm, 78% unruptured). Complete aneurysmal occlusion rate was 68% (95% CI 58.7% to 76.1%, I2=67%) at mean angiographic follow-up of 16 months. Subgroup analysis of FD as a standalone treatment estimated a complete occlusion rate of 69% (95% CI 50% to 83%, I2=38%). The total complication rate was 22% (95% CI 16.7% to 28.6%, I2=51%), largely due to an ischemic complication rate of 16% (95% CI 10.8% to 21.9%, I2=55%). The etiologies of ischemic complications were largely due to jailed artery hypoperfusion (47%) and in-stent thrombosis (38%). 7% of patients suffered permanent symptomatic complications (95% CI 4.5% to 9.8%, I2=6%).

Conclusion FD treatment of bifurcation aneurysms has a modest efficacy and relatively unfavorable safety profile. Proceduralists may consider reserving FD as a treatment option if no other surgical or endovascular therapy is deemed feasible.

  • Flow Diverter
  • Device
  • Aneurysm
  • Stent

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors AIK and NM were involved in the design and conception of this manuscript. AIK and MEE performed the literature search. AIK, MEE, and JCP compiled the primary manuscript. AIK and MEE compiled the figures and tables. All authors critically revised the manuscript and have approved the manuscript as it is written. NM is the guarantor of the study.

  • 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 MB is a consultant for Cerenovus, consultant for Integra, and a member of the advisory board for Stryker. GT is a consultant for Dynamed and a Steering Committee member for Medtronic. GT is an Associate Editor for Journal of Neurointerventional Surgery. All other authors have no conflicts of interest to report.

  • Provenance and peer review Not commissioned; externally 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.