Flow diversion for treatment of acutely ruptured intracranial aneurysms: Comparison of complications and clinical outcomes with coil embolization

Abstract

Introduction

Although flow diversion (FD) has become a major treatment modality for unruptured intracranial aneurysms, it has been used as an off-label therapy for ruptured aneurysms whose morphologies or other characteristics may not be amenable to traditional coil embolization (CE). Previous literature has demonstrated high angiographic occlusion rates for FD in the acute setting, but also high rates of peri-procedural complications (some of which result from use of dual anti-platelet therapy).

Methods

Aneurysmal subarachnoid hemorrhage (aSAH) hospitalizations treated with endovascular therapy were identified in the National Inpatient Sample (NIS) in 2020. The primary exposure was treatment with FD (identified using a dedicated ICD-10-CM billing code specifying FD intraluminal device), and the primary endpoints were favorable outcome (defined by the NIS Subarachnoid Hemorrhage Outcome Measure, shown to have high concordance with modified Rankin Scale scores < 2 at 90 days following discharge) and peri-procedural ischemic and hemorrhagic complications (PPIHC). Endpoints were compared between FD and CE following 1:1 propensity score matching, adjusting for age, Hunt and Hess grade, comorbidity burden, and aneurysm location.

Results

7780 aSAH hospitalizations were identified, 150 (1.9%) of which documented treatment with FD, the remainder with CE. 16.7% of FD procedures were preceded by CE. Median treatment time with FD was admission day 1 (1–8) (IQR). Favorable outcomes were achieved in 46.7% of FD cases (and in 47.6% of CE cases), while PPIHC complications were seen in less than 3.3% of cases (and in 2.1% of CE cases). Following propensity score adjustment, 150 FD cases were matched to 150 CE cases, and rates of favorable outcome (46.7% vs. 50.0%, p = 0.563) and PPIHC (3.3% vs. 6.7%, p = 0.185) did not differ between the two treatment modalities.

Conclusion

FD demonstrated similar clinical outcomes and complication rates in comparison with CE for the treatment of ruptured aneurysms.