Diffusion-weighted imaging-detected ischemic lesions associated with flow-diverting stents in intracranial aneurysms: safety, potential mechanisms, clinical outcome, and concerns

J Neurosurg. 2015 Mar;122(3):627-36. doi: 10.3171/2014.10.JNS132566. Epub 2015 Jan 6.


Object: It was initially considered safe for flow-diverting stents to cover the ostia of branching vessels during endovascular procedures for the treatment of intracranial aneurysms. As more recent evidence suggests, however, their use is not always free of ischemic concerns in terms of covered arterial ostia. The authors sought to determine the frequency of silent and clinically evident diffusion-weighted imaging (DWI)-detected abnormalities related to stent placement as a means of elucidating potential clinical risks.

Methods: This is a prospective single-center study on a series of patients with intracranial aneurysms that were treated with flow-diverting stents. All patients systematically underwent an MRI protocol that included DWI before treatment, between 24 and 48 hours postprocedure, and 3 months postembolization. Effectiveness of anticoagulation treatment was assessed for all patients. Lesions seen on DWI were correlated to the parent artery and the side-branch territories and were statistically analyzed in relation to their time of occurrence and clinical presentation. The authors compared the DWI findings in these patients to findings obtained in patients treated with a stent-assisted coiling technique during the same time period.

Results: Over the course of 18 consecutive months, 38 consecutive patients (7 males and 31 females) with 49 intracranial aneurysms were treated using flow-diverting stents. Overall, 81.6% of the DWI spots found remained clinically silent during the follow-up period. Five ischemic clinical complications (13.2%) occurred in the postprocedural period. No statistically significant correlation could be established between DWI spots or aneurysm location and clinical complications or follow-up modified Rankin Scale score at 3 months. The complication rate was 7.8% (n = 3) at the 3-month follow-up, and mortality was 0%. Compared with stent-assisted coiling, use of flow-diverting stents showed a statistically significant correlation with silent DWI findings postintervention.

Conclusions: Lesions seen on DWI resulting from the procedure are far more common than anticipated, but the technique remains safe and effective, providing an interesting alternative for "difficult" aneurysms, regardless of location. Late-occurring DWI-detected lesions distal to side arterial branches imply a local pressure gradient drop, related to flow competition by collateral networks. Further research is needed to assess the extent and significance of these events.

Keywords: ACA = anterior cerebral artery; AChA = anterior choroidal artery; ACoA = anterior communicating artery; ARU = aspirin reaction unit; DSA = digital subtraction angiography; DWI = diffusion-weighted imaging; ECA = external carotid artery; MCA = middle cerebral artery; OKM = O'Kelly and Marotta; PCoA = posterior communicating artery; PRU = P2Y12 reactivity unit; SAH = subarachnoid hemorrhage; VA = vertebral artery; brain ischemia; cICA = cavernous segment of the internal carotid artery; diffusion-weighted imaging; intracranial aneurysms; mRS = modified Rankin Scale; stent; vascular disorders.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Brain Ischemia / diagnosis*
  • Brain Ischemia / etiology*
  • Brain Ischemia / mortality
  • Diffusion Magnetic Resonance Imaging / methods*
  • Female
  • Follow-Up Studies
  • Humans
  • Image Processing, Computer-Assisted
  • Intracranial Aneurysm / complications*
  • Intracranial Aneurysm / mortality
  • Intracranial Aneurysm / surgery
  • Male
  • Middle Aged
  • Neurosurgical Procedures / adverse effects
  • Neurosurgical Procedures / methods
  • Postoperative Complications / diagnosis*
  • Postoperative Complications / mortality
  • Prospective Studies
  • Safety
  • Stents / adverse effects*
  • Treatment Outcome
  • Young Adult