• Renuka Chintapalli, Sarah Nguyen, Philipp Taussky, Ramesh Grandhi, Philipp Dammann, Kunal Raygor, Daniel A Tonetti, Tommy Andersson, Philip White, Christopher S Ogilvy, Rene Chapot, W Christopher Fox, Rabih G Tawk, Giuseppe Lanzino, Ricardo Hanel, Ashutosh Jadhav, Ameer E Hassan, Italo Linfante, Rami Almefty, Justin Mascitelli, Kyle Fargen, Michael R Levitt, Jan-Karl Burkhardt, Brian T Jankowitz, Pascal Jabbour, Robert M Starke, Bradley A Gross, Peter Kan, Monika Killer-Oberpfalzer, Riitta Rautio, Adam A Dmytriw, Alan Coulthard, Guilherme Dabus, Daniel Raper, Cornelius Deuschl, Craig Kilburg, Karol P Budohoski, and Adib A Abla.
• 1School of Clinical Medicine, University of Cambridge, United Kingdom.
• J. Neurosurg. 2024 May 31: 1101-10.

ObjectiveThe placement of flow-diverting devices has become a common method of treating unruptured intracranial aneurysms of the internal carotid artery. The progressive improvement of aneurysm occlusion after treatment-with low complication and rupture rates-has led to a dilemma regarding the management of aneurysms in which occlusion has not occurred within 6-24 months. The authors aimed to identify clinical consensus regarding management of intracranial aneurysms displaying persistent filling 6-24 months after flow diversion and to ascertain questions that may drive future investigation.MethodsAn international panel of 67 experts was invited to participate in a multistep Delphi consensus process on the treatment of intracranial aneurysms after failed flow diversion.ResultsOf the 67 experts invited, 23 (34%) participated. Qualitative analysis of an initial survey with open-ended questions resulted in 51 statements regarding management of aneurysms showing persistent filling after flow diversion. The statements were grouped into 8 categories, and in the second round, respondents rated the degree of their agreement with each statement on a 5-point Likert scale. Flow diverters with surface modifiers did not influence administration of dual-antiplatelet therapy according to 83%. Consensus was also reached regarding the definition of treatment failure at specific time points, including at 6 months if there is aneurysm growth or persistent rapid flow through the entirety of the aneurysm (96%), at 12 months if there is aneurysm growth or symptom onset (78%), and at 24 months if there is persistent filling regardless of size and filling characteristics (74%). Although experts agreed that the degree of intimal hyperplasia or in-device stenosis could not be ascertained by noninvasive imaging alone (83%), only 65% chose digital subtraction angiography as the preferred modality. At 6 and 12 months, retreatment is preferred if there is persistent filling with aneurysm growth (96%, 96%), device malposition (48%, 87%), or a history of subarachnoid hemorrhage (65%, 70%), respectively, and at 24 months if there is persistent filling without reduction in aneurysm size (74%). Experts favored treatment with an additional flow diverter (87%) over aneurysm clipping, applying the same principles for follow-up (83%) and treatment failure (91%) as for the first flow diverter.ConclusionsThe authors present the consensus practices of experts in the management of intracranial aneurysms without occlusion 6-24 months after treatment with a flow-diverting device.

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